=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730804337
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NORTHSIDE FAMILY EYE CARE OPTOMETRY, PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/05/2022
-----------------------------------------------------
Last Update Date | 10/05/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5811 RAMSEY ST
-----------------------------------------------------
City | FAYETTEVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28311-3416
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-884-9922
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10512 GILES RD
-----------------------------------------------------
City | LINDEN
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28356-9343
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-884-9922
-----------------------------------------------------
Fax | 910-401-1329
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CREDENTIALING
-----------------------------------------------------
Name | CHRISTI HARDISON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 910-574-8420
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------