Healthcare Provider Details

I. General information

NPI: 1376722231
Provider Name (Legal Business Name): KOALA EYE CENTRE PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/29/2007
Last Update Date: 04/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

719 GREEN VALLEY RD STE. 303
GREENSBORO NC
27408-7014
US

IV. Provider business mailing address

719 GREEN VALLEY RD STE. 303
GREENSBORO NC
27408-7014
US

V. Phone/Fax

Practice location:
  • Phone: 336-378-2511
  • Fax: 336-378-1186
Mailing address:
  • Phone: 336-378-2511
  • Fax: 336-378-1186

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QS0132X
TaxonomyOphthalmologic Surgery Clinic/Center
License Number200100470
License Number StateNC

VIII. Authorized Official

Name: MICHAEL ANTONIO SPENCER
Title or Position: PRESIDENT/ OWNER
Credential: M.D.
Phone: 336-378-2511