Healthcare Provider Details

I. General information

NPI: 1609909555
Provider Name (Legal Business Name): ACADEMY EYE CENTER OPTOMETRY, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/13/2007
Last Update Date: 01/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

209 W NAOMI ST
RANDLEMAN NC
27317-1733
US

IV. Provider business mailing address

1120 RANDOLPH ST SUITE 32
THOMASVILLE NC
27360-5174
US

V. Phone/Fax

Practice location:
  • Phone: 336-495-5700
  • Fax: 336-495-1174
Mailing address:
  • Phone: 336-475-0143
  • Fax: 336-472-6831

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1464
License Number StateNC

VII. Legacy identifiers

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

# 1
Identifier0853510001
Identifier TypeOTHER
Identifier StateNC
Identifier IssuerCIGNA GOVERNMENT SERVIES MEDICARE PART B DME
# 2
Identifier011KT
Identifier TypeOTHER
Identifier StateNC
Identifier IssuerBCBS GROUP-R
# 3
Identifier89011KP
Identifier TypeMEDICAID
Identifier StateNC
Identifier Issuer

VIII. Authorized Official

Name: DANFORD RAYNOR
Title or Position: PRESIDENT
Credential: OD
Phone: 336-460-0499