=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770815722
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KERNERSVILLE EYE ASSOCIATES, O.D., P.A.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/02/2010
-----------------------------------------------------
Last Update Date | 09/03/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1030 S MAIN ST SUITE Q
-----------------------------------------------------
City | KERNERSVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27284-7490
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-992-0010
-----------------------------------------------------
Fax | 336-245-4636
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1635 NC HIGHWAY 66 S STE 155
-----------------------------------------------------
City | KERNERSVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27284-3855
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-992-0010
-----------------------------------------------------
Fax | 336-245-4636
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. ARUN T SUBRAMANIAN
-----------------------------------------------------
Credential | O.D., F.A.A.O.
-----------------------------------------------------
Telephone | 336-992-0010
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 2006
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------