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General NPI Number Information
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NPI Number | 1952635278
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Entity Type | Organization
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Legal Business Name | WILLANE A. WYLIE, O.D. & ASSOCIATES, P.A.
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Dates
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Enumeration Date | 09/21/2009
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Last Update Date | 09/22/2009
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Provider Practice Location Address
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Address Line | 9820 CALLABRIDGE CT
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City | CHARLOTTE
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State | NC
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Zip | 28216-7669
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Country | US
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Telephone | 704-398-9115
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Fax |
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Provider Business Mailing Address
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Address Line | 1948 OROVILLE CT
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City | CHARLOTTE
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State | NC
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Zip | 28214-2567
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Country | US
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Telephone | 704-575-6796
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Fax |
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Authorized Official
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Title or Position | OWNER/OPTOMETRIST
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Name | WILLANE ARETTA WYLIE
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Credential | O.D.
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Telephone | 704-575-6796
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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 | 1824
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License Number State | NC
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