Provider Demographics
NPI:1083903074
Name:MCKINNON EYE CLINIC, P.A.
Entity type:Organization
Organization Name:MCKINNON EYE CLINIC, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/TREASURER
Authorized Official - Prefix:
Authorized Official - First Name:STEVE
Authorized Official - Middle Name:
Authorized Official - Last Name:MCKINNON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:704-873-1463
Mailing Address - Street 1:PO BOX 991
Mailing Address - Street 2:
Mailing Address - City:STATESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28687-0991
Mailing Address - Country:US
Mailing Address - Phone:704-873-1463
Mailing Address - Fax:
Practice Address - Street 1:399 3RD AVE SW
Practice Address - Street 2:
Practice Address - City:TAYLORSVILLE
Practice Address - State:NC
Practice Address - Zip Code:28681-4180
Practice Address - Country:US
Practice Address - Phone:828-632-9005
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-31
Last Update Date:2011-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8957138Medicaid