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General NPI Number Information
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NPI Number | 1154367217
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Entity Type | Organization
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Legal Business Name | PROVIDENCE EYE AND LASER SPECIALISTS, PC
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Dates
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Enumeration Date | 06/20/2006
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Last Update Date | 10/16/2012
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Provider Practice Location Address
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Address Line | 3025 SPRINGBANK LN SUITE 200
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City | CHARLOTTE
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State | NC
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Zip | 28226-3362
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Country | US
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Telephone | 704-540-9595
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Fax | 704-540-9616
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Provider Business Mailing Address
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Address Line | 3025 SPRINGBANK LN SUITE 200
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City | CHARLOTTE
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State | NC
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Zip | 28226-3362
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Country | US
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Telephone | 704-540-9595
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Fax | 704-540-9616
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | REY WILSON
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Credential |
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Telephone | 704-540-9595
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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 | 2000-00102
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License Number State | NC
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