Provider Demographics
NPI:1154503027
Name:PROFESSIONAL OPTICAL COMPANY OF WILMINGTON, INC.
Entity type:Organization
Organization Name:PROFESSIONAL OPTICAL COMPANY OF WILMINGTON, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:L
Authorized Official - Last Name:BAYSE
Authorized Official - Suffix:
Authorized Official - Credentials:LICENSED OPTICIAN
Authorized Official - Phone:910-392-6550
Mailing Address - Street 1:2226 S 17TH ST
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28401-7515
Mailing Address - Country:US
Mailing Address - Phone:910-392-6550
Mailing Address - Fax:910-784-9293
Practice Address - Street 1:2226 S 17TH ST
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28401-7515
Practice Address - Country:US
Practice Address - Phone:910-392-6550
Practice Address - Fax:910-784-9293
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-03
Last Update Date:2011-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC292332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC093EHOtherBCBS
NCNC0292OtherEYEMED
NC0903JOtherBCBS HEALTHCHOICE
NC8801815Medicaid
NC0903JOtherBCBS HEALTHCHOICE