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General NPI Number Information
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NPI Number | 1649573551
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Entity Type | Organization
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Legal Business Name | QUEEN CITY EYE CENTER, O.D., PLLC
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Dates
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Enumeration Date | 12/15/2010
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Last Update Date | 12/15/2010
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Provider Practice Location Address
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Address Line | 1801 WINDSOR SQUARE DR
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City | MATTHEWS
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State | NC
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Zip | 28105-4662
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Country | US
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Telephone | 704-999-6986
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Fax | 704-815-7584
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Provider Business Mailing Address
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Address Line | 3515 SELWYN AVE
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City | CHARLOTTE
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State | NC
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Zip | 28209-3501
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Country | US
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Telephone | 704-999-6986
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Fax | 704-815-7584
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Authorized Official
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Title or Position | MANAGING PARTNER
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Name | DR. ERIC CLARK DUDLEY
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Credential | O.D.
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Telephone | 704-999-6986
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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 | 1889
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License Number State | NC
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