=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013253418
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DAVID WICHNOKSI OD PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/13/2012
-----------------------------------------------------
Last Update Date | 12/13/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 200 S COLLEGE ST STE 307
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28202-2065
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-334-4444
-----------------------------------------------------
Fax | 704-334-4441
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7615 COLONY RD
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28226-5017
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-543-9000
-----------------------------------------------------
Fax | 704-543-9002
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. DAVID J WICHNOSKI
-----------------------------------------------------
Credential | OD
-----------------------------------------------------
Telephone | 704-543-9000
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 1632
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------