=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578628780
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MASON & MINCEY OD PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/27/2006
-----------------------------------------------------
Last Update Date | 10/10/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2396 E FRANKLIN BLVD
-----------------------------------------------------
City | GASTONIA
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28054-4727
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-864-7878
-----------------------------------------------------
Fax | 704-868-9591
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 5149 2396 E FRANKLIN BLVD
-----------------------------------------------------
City | GASTONIA
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28054-0020
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-864-7878
-----------------------------------------------------
Fax | 704-868-9591
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. JOHN SCOTT MINCEY
-----------------------------------------------------
Credential | OD
-----------------------------------------------------
Telephone | 704-477-1283
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 1529
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------