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General NPI Number Information
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NPI Number | 1528141009
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Entity Type | Organization
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Legal Business Name | CAROLINA CENTER FOR EYE CARE, OD PA
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Dates
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Enumeration Date | 10/20/2006
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Last Update Date | 04/29/2021
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Provider Practice Location Address
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Address Line | 5380 US HIGHWAY 158 SUITE 100
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City | ADVANCE
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State | NC
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Zip | 27006-6907
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Country | US
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Telephone | 336-940-2015
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Fax | 336-940-2069
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Provider Business Mailing Address
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Address Line | 5380 US HIGHWAY 158 SUITE 100
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City | ADVANCE
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State | NC
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Zip | 27006-6907
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Country | US
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Telephone | 336-940-2015
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Fax | 336-940-2069
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Authorized Official
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Title or Position | OWNER
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Name | DR. ELLYN VICTORIA JOHNSON
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Credential | OD
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Telephone | 336-940-2015
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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 | 1813
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License Number State | NC
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