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General NPI Number Information
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NPI Number | 1215080114
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Entity Type | Organization
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Legal Business Name | UPCHURCH OPTICAL
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Dates
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Enumeration Date | 01/22/2007
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Last Update Date | 10/09/2007
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Provider Practice Location Address
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Address Line | 5108 N ROXBORO RD
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City | DURHAM
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State | NC
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Zip | 27704-1420
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Country | US
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Telephone | 919-477-9113
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Fax | 919-479-1797
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Provider Business Mailing Address
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Address Line | 5108 N ROXBORO RD
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City | DURHAM
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State | NC
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Zip | 27704-1420
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Country | US
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Telephone | 919-477-9113
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Fax | 919-479-1797
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Authorized Official
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Title or Position | OPTICIAN OWNER
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Name | MR. MICHAEL ARTHUR UPCHURCH
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Credential | OPTICIAN
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Telephone | 919-477-9113
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332H00000X
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Taxonomy Name | Eyewear Supplier
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License Number | 0612
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License Number State | NC
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