Healthcare Provider Details

I. General information

NPI: 1942284880
Provider Name (Legal Business Name): PEMBROKE OPTOMETRIC CLINIC PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/05/2005
Last Update Date: 02/12/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

204 UNION CHAPEL RD
PEMBROKE NC
28372-2109
US

IV. Provider business mailing address

PO BOX 2109
PEMBROKE NC
28372-2109
US

V. Phone/Fax

Practice location:
  • Phone: 910-521-9744
  • Fax: 910-521-1310
Mailing address:
  • Phone: 910-521-9744
  • Fax: 910-521-1310

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1318
License Number StateNC

VIII. Authorized Official

Name: DR. SANDRA KAYE LOCKLEAR
Title or Position: PRESIDENT
Credential: OD
Phone: 910-521-9744