Provider Demographics
NPI:1972724201
Name:ACADEMY EYE CENTER OPTOMETRY, PA
Entity type:Organization
Organization Name:ACADEMY EYE CENTER OPTOMETRY, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JENNIE
Authorized Official - Middle Name:
Authorized Official - Last Name:MITCHELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-905-9745
Mailing Address - Street 1:213 W NAOMI ST
Mailing Address - Street 2:
Mailing Address - City:RANDLEMAN
Mailing Address - State:NC
Mailing Address - Zip Code:27317-1733
Mailing Address - Country:US
Mailing Address - Phone:336-495-3019
Mailing Address - Fax:336-495-5703
Practice Address - Street 1:1040 RANDOLPH ST
Practice Address - Street 2:SUITE 32
Practice Address - City:THOMASVILLE
Practice Address - State:NC
Practice Address - Zip Code:27360-6383
Practice Address - Country:US
Practice Address - Phone:336-475-0151
Practice Address - Fax:336-472-6831
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-02
Last Update Date:2009-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1464152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5901580Medicaid
NC0853510001OtherCIGNA GOVERNMENT SERVICES MEDICARE PART B DME
NC011KTOtherBCBS GROUP-T
NC011KTOtherBCBS GROUP-T