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General NPI Number Information
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NPI Number | 1699956227
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Entity Type | Organization
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Legal Business Name | CHARLOTTE OPTOMETRIC CLINIC, PA
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Dates
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Enumeration Date | 11/26/2007
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Last Update Date | 11/21/2023
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Provider Practice Location Address
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Address Line | 9425 SOUTH BLVD STE A
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City | CHARLOTTE
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State | NC
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Zip | 28273-6900
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Country | US
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Telephone | 704-341-7676
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Fax | 704-370-9751
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Provider Business Mailing Address
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Address Line | 9425 SOUTH BLVD STE A
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City | CHARLOTTE
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State | NC
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Zip | 28273-6900
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Country | US
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Telephone | 704-341-7676
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Fax | 704-370-9751
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Authorized Official
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Title or Position | OPTOMETRIST
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Name | DR. MASHERRILL KOONCE
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Credential | O.D.
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Telephone | 704-341-7676
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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 | 1393
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License Number State | NC
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