=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578042388
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CENTRAL CAROLINA OPTOMETRY, P.A.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/13/2018
-----------------------------------------------------
Last Update Date | 08/13/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3310 HWY 87
-----------------------------------------------------
City | SANFORD
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27332
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 197-743-3100
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5149 LINKSLAND DR
-----------------------------------------------------
City | HOLLY SPRINGS
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27540-9155
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 919-557-0957
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DR
-----------------------------------------------------
Name | DR. KATHERINE H JOHNSON
-----------------------------------------------------
Credential | OD
-----------------------------------------------------
Telephone | 919-417-2957
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 1367
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------