Healthcare Provider Details

I. General information

NPI: 1619813318
Provider Name (Legal Business Name): JOHN REYNOLDS TODD OPTICIAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/25/2026
Last Update Date: 04/25/2026
Certification Date: 04/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1511 BENVENUE RD
ROCKY MOUNT NC
27804-6383
US

IV. Provider business mailing address

1511 BENVENUE RD
ROCKY MOUNT NC
27804-6383
US

V. Phone/Fax

Practice location:
  • Phone: 252-442-5666
  • Fax: 252-442-8650
Mailing address:
  • Phone: 252-442-5666
  • Fax: 252-442-8650

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156FX1800X
TaxonomyOptician
License Number1052
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: