=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679535504
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CAPE FEAR OPTOMETRIC CLINIC PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/05/2006
-----------------------------------------------------
Last Update Date | 04/17/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1613 OWEN DR
-----------------------------------------------------
City | FAYETTEVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28304-3425
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-484-6178
-----------------------------------------------------
Fax | 910-323-3048
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1613 OWEN DR
-----------------------------------------------------
City | FAYETTEVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28304-3425
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-484-6178
-----------------------------------------------------
Fax | 910-323-3048
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT OPTOMETRIST
-----------------------------------------------------
Name | DR. WILLIAM CHARLESS PHILBRICK
-----------------------------------------------------
Credential | OD
-----------------------------------------------------
Telephone | 910-484-6178
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 844
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------