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General NPI Number Information
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NPI Number | 1114201936
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Entity Type | Organization
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Legal Business Name | INNOVATIVE EYE CARE OD PLLC
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Dates
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Enumeration Date | 09/29/2011
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Last Update Date | 02/28/2012
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Provider Practice Location Address
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Address Line | 1710 KENILWORTH AVE SUITE 210
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City | CHARLOTTE
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State | NC
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Zip | 28203-5256
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Country | US
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Telephone | 704-348-1500
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Fax |
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Provider Business Mailing Address
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Address Line | 1710 KENILWORTH AVE SUITE 210
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City | CHARLOTTE
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State | NC
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Zip | 28203-5256
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Country | US
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Telephone | 704-348-1500
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Fax | 704-919-0289
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Authorized Official
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Title or Position | OWNER
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Name | DR. MICHELLE KATHLEEN MUMFORD
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Credential | O.D.
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Telephone | 704-348-1500
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 2225
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License Number State | NC
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