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General NPI Number Information
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NPI Number | 1235270174
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Entity Type | Individual
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Provider Name | JUSTIN DAVID LANE O.D.
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Gender | Male
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Dates
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Enumeration Date | 02/12/2007
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Last Update Date | 11/27/2016
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Provider Practice Location Address
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Address Line | 1345 WESTERN BLVD STE 120B
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City | JACKSONVILLE
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State | NC
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Zip | 28546-7627
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Country | US
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Telephone | 910-376-8229
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Fax |
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Provider Business Mailing Address
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Address Line | 120 WYNDHAM WAY
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City | WILMINGTON
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State | NC
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Zip | 28411-6710
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Country | US
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Telephone | 910-508-4127
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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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 | 2030
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License Number State | NC
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