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General NPI Number Information
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NPI Number | 1619366507
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Entity Type | Organization
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Legal Business Name | SOUTH FORK OPTOMETRIC ASSOCIATES, P.A.
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Dates
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Enumeration Date | 01/14/2015
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Last Update Date | 01/14/2015
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Provider Practice Location Address
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Address Line | 9820 CALLABRIDGE CT
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City | CHARLOTTE
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State | NC
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Zip | 28216-7669
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Country | US
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Telephone | 704-394-3886
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Fax |
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Provider Business Mailing Address
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Address Line | 307 ETHAN LN
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City | BELMONT
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State | NC
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Zip | 28012-4116
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | JOSEPH FAULK
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Credential |
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Telephone | 704-394-3886
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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 | 2255
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License Number State | NC
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Taxonomy #2
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 2328
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License Number State | NC
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