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General NPI Number Information
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NPI Number | 1629528104
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Entity Type | Organization
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Legal Business Name | OLIVER OPTOMETRIC EYE CARE
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Dates
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Enumeration Date | 10/10/2016
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Last Update Date | 01/17/2017
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Provider Practice Location Address
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Address Line | 18 GRAYSON ST
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City | SPARTA
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State | NC
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Zip | 28675-6006
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Country | US
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Telephone | 336-372-4493
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Fax | 336-372-2035
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Provider Business Mailing Address
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Address Line | PO BOX 1119
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City | SPARTA
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State | NC
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Zip | 28675-1119
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Country | US
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Telephone | 336-372-4493
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Fax | 336-372-2035
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Authorized Official
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Title or Position | OPTOMETRIST
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Name | LOGAN J OLIVER
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Credential | OD
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Telephone | 336-372-4493
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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 | 2461
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License Number State | NC
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