Healthcare Provider Details

I. General information

NPI: 1649394891
Provider Name (Legal Business Name): EYEWEAR UNLIMITED OPTICAL SHOP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/16/2007
Last Update Date: 08/05/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

224 TOWN RUN LN
WINSTON SALEM NC
27101-3911
US

IV. Provider business mailing address

224 TOWN RUN LN
WINSTON SALEM NC
27101-3911
US

V. Phone/Fax

Practice location:
  • Phone: 336-723-0748
  • Fax: 336-721-4711
Mailing address:
  • Phone: 336-723-0748
  • Fax: 336-721-4711

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number21915
License Number StateNC

VIII. Authorized Official

Name: JAMES DAVID BRANCH
Title or Position: OWNER
Credential: MD
Phone: 336-723-0748