Healthcare Provider Details

I. General information

NPI: 1073788923
Provider Name (Legal Business Name): BLACK OPTOMETRIC EYE ASSOCIATES,PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/22/2008
Last Update Date: 02/21/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

518 W JOHN ST
MATTHEWS NC
28105-5353
US

IV. Provider business mailing address

518 W JOHN ST
MATTHEWS NC
28105-5353
US

V. Phone/Fax

Practice location:
  • Phone: 704-847-9833
  • Fax:
Mailing address:
  • Phone: 704-847-9833
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1176
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number1176
License Number StateNC

VIII. Authorized Official

Name: DR. DEBORAH BLACK
Title or Position: PRESIDENT/OWNER
Credential: O.D.
Phone: 704-847-9833