MEDICARE: EYECARECENTER OD PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist		NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0222680042	OTHER	NC	SUPPLIER NUMBER

General Provider Information

NPI Number	:	1346781721
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EYECARECENTER OD PA

Provider Business Mailing Address
First Line	:	PO BOX 207261
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75320-7261
Country	:	US
Telephone Number	:	636-200-4393
Fax Number	:	636-527-0766

Provider Business Practice Location Address
First Line	:	1575 NC HIGHWAY 66 S
Second Line	:
City	:	KERNERSVILLE
State	:	NC
Zip	:	27284-3516
Country	:	US
Telephone Number	:	336-993-8514
Fax Number	:	336-336-9936

Authorized Official
Title or Position	:	AUTHORIZED OFFICIAL
Name	:	DR. ALISON BAILEY
Credential	:	OD
Telephone Number	:	636-200-4393

Provider Enumeration Date	:	03/17/2017
Last Update Date	:	09/29/2023

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