Healthcare Provider Details

I. General information

NPI: 1275533960
Provider Name (Legal Business Name): MIRIAM J LAVELLE OD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/26/2005
Last Update Date: 01/28/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

917 RIDGE RD
ROXBORO NC
27573-4511
US

IV. Provider business mailing address

917 RIDGE RD
ROXBORO NC
27573-4511
US

V. Phone/Fax

Practice location:
  • Phone: 336-599-0138
  • Fax: 336-599-0080
Mailing address:
  • Phone: 336-599-0138
  • Fax: 336-599-0080

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberNC1282
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: