Provider Demographics
NPI:1104071695
Name:HILLCREST VISION, O.D., P.A.
Entity type:Organization
Organization Name:HILLCREST VISION, O.D., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JUAWANA
Authorized Official - Middle Name:COLEMAN
Authorized Official - Last Name:HALL
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:336-760-2020
Mailing Address - Street 1:2341 WINTERHAVEN LN
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-6792
Mailing Address - Country:US
Mailing Address - Phone:336-760-2020
Mailing Address - Fax:336-760-2858
Practice Address - Street 1:2341 WINTERHAVEN LN
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-6792
Practice Address - Country:US
Practice Address - Phone:336-760-2020
Practice Address - Fax:336-760-2858
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-25
Last Update Date:2013-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2000152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5902677Medicaid
NC6159840001Medicare NSC
NC5902677Medicaid