Healthcare Provider Details

I. General information

NPI: 1720261662
Provider Name (Legal Business Name): MOUNT HOLLY EYE CLINIC, OD, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/13/2007
Last Update Date: 01/14/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

612 S MAIN ST
MOUNT HOLLY NC
28120-1653
US

IV. Provider business mailing address

612 S MAIN ST
MOUNT HOLLY NC
28120-1653
US

V. Phone/Fax

Practice location:
  • Phone: 704-822-0099
  • Fax: 704-822-0077
Mailing address:
  • Phone: 704-822-0099
  • Fax: 704-822-0077

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1387
License Number StateNC

VIII. Authorized Official

Name: DR. ANGELA MARIE FOX-PUTNAM
Title or Position: OWNER
Credential: OD
Phone: 704-822-0099