Healthcare Provider Details

I. General information

NPI: 1417945775
Provider Name (Legal Business Name): GASTON EYE ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/11/2005
Last Update Date: 08/04/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2325 ABERDEEN BLVD STE A
GASTONIA NC
28054-0614
US

IV. Provider business mailing address

2325 ABERDEEN BLVD STE A
GASTONIA NC
28054-0614
US

V. Phone/Fax

Practice location:
  • Phone: 704-853-3937
  • Fax: 704-853-0840
Mailing address:
  • Phone: 704-853-3937
  • Fax: 704-853-0840

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number State

VIII. Authorized Official

Name: DR. BOB MCCULLEN JR.
Title or Position: MANAGING PARTNER
Credential: M.D.
Phone: 704-853-3937