=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205510799
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TRIANGLE EYE CONSTITUENTS, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/14/2023
-----------------------------------------------------
Last Update Date | 06/14/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9650 BRIER CREEK PKWY STE 103
-----------------------------------------------------
City | RALEIGH
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27617-6504
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 803-200-2071
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7512 KARLEY CT
-----------------------------------------------------
City | INDIAN LAND
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29707-5901
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 803-517-1060
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICIAN OWNER OFFICER
-----------------------------------------------------
Name | KEVIN NUSZ
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 803-517-1060
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207W00000X
-----------------------------------------------------
Taxonomy Name | Ophthalmology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------