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General NPI Number Information
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NPI Number | 1669749388
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Entity Type | Organization
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Legal Business Name | DR. CHARLES R. PRUDEN JR. OD
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Dates
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Enumeration Date | 11/23/2011
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Last Update Date | 11/28/2011
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Provider Practice Location Address
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Address Line | 211 VANCE ST E
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City | WILSON
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State | NC
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Zip | 27893-4117
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Country | US
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Telephone | 252-237-9191
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Fax | 252-237-3918
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Provider Business Mailing Address
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Address Line | PO BOX 757
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City | WILSON
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State | NC
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Zip | 27894-0757
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Country | US
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Telephone | 252-237-9191
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Fax | 252-237-3918
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Authorized Official
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Title or Position | OPTOMETRIST
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Name | DR. CHARLES ROY PRUDEN JR.
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Credential | OD
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Telephone | 252-237-9191
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332H00000X
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Taxonomy Name | Eyewear Supplier
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License Number | 746
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License Number State | NC
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