Healthcare Provider Details

I. General information

NPI: 1134758295
Provider Name (Legal Business Name): THERESA ANN WATT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/02/2020
Last Update Date: 07/28/2021
Certification Date: 07/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1102C YADKINVILLE RD
MOCKSVILLE NC
27028-2037
US

IV. Provider business mailing address

720 SHEARERS RD
MOORESVILLE NC
28115-9777
US

V. Phone/Fax

Practice location:
  • Phone: 336-751-5734
  • Fax: 336-751-4968
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2629
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: