Healthcare Provider Details

I. General information

NPI: 1255491528
Provider Name (Legal Business Name): KNIGHTDALE EYECARE OPTOMETRIC, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/09/2006
Last Update Date: 07/15/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

742 MCKNIGHT DR SUITE 100
KNIGHTDALE NC
27545-7764
US

IV. Provider business mailing address

742 MCKNIGHT DR SUITE 100
KNIGHTDALE NC
27545-7764
US

V. Phone/Fax

Practice location:
  • Phone: 919-266-2048
  • Fax: 919-266-4648
Mailing address:
  • Phone: 919-266-2048
  • Fax: 919-266-4648

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number1646
License Number StateNC

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier410034712
Identifier TypeOTHER
Identifier StateNC
Identifier IssuerRAILROAD MEDICARE

VIII. Authorized Official

Name: DR. TIMOTHY JOHN POIRIER
Title or Position: OWNER
Credential: O.D.
Phone: 919-266-2048