Healthcare Provider Details

I. General information

NPI: 1063786317
Provider Name (Legal Business Name): DAVID R MCDANIEL OD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/05/2012
Last Update Date: 03/08/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

510 W KING ST
KINGS MTN NC
28086-3310
US

IV. Provider business mailing address

510 W KING ST PO BOX 1127
KINGS MTN NC
28086-3310
US

V. Phone/Fax

Practice location:
  • Phone: 704-739-1394
  • Fax:
Mailing address:
  • Phone: 704-739-1394
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberNC0991
License Number StateNC

VIII. Authorized Official

Name: DR. DAVID RONALD MCDANIEL
Title or Position: PRESIDENT/CEO
Credential: OD
Phone: 704-739-1394