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General NPI Number Information
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NPI Number | 1295030989
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Entity Type | Organization
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Legal Business Name | OPTOMETRIC EYE CLINIC, P.A.
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Dates
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Enumeration Date | 01/11/2011
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Last Update Date | 09/30/2024
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Provider Practice Location Address
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Address Line | 622 N MAIN ST
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City | MOORESVILLE
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State | NC
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Zip | 28115-2312
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Country | US
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Telephone | 704-664-5406
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Fax | 704-663-6498
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Provider Business Mailing Address
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Address Line | 622 N MAIN ST
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City | MOORESVILLE
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State | NC
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Zip | 28115-2312
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Country | US
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Telephone | 704-664-5406
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Fax | 704-663-6498
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Authorized Official
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Title or Position | OPTOMETRIST
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Name | PEGGY LYNN WIKE
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Credential | O.D.
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Telephone | 704-664-5406
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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 | 1130
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License Number State | NC
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