1063981900 NPI number — CLARK OPTOMETRIC CENTER OF SC, P.A.

Table of content: (NPI 1063981900)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063981900 NPI number — CLARK OPTOMETRIC CENTER OF SC, P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CLARK OPTOMETRIC CENTER OF SC, P.A.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1063981900
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/30/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
200 PERIMETER PARK DRIVE
Provider Second Line Business Mailing Address:
UNIT D
Provider Business Mailing Address City Name:
MORRISVILLE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27560
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
919-544-4097
Provider Business Mailing Address Fax Number:
919-678-3814

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
419 SE MAIN ST STE 300
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SIMPSONVILLE
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29681-2676
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
864-417-2345
Provider Business Practice Location Address Fax Number:
864-399-4519
Provider Enumeration Date:
11/21/2018

Additional Information

Authorized Official

Authorized Official Last Name:
CLARK
Authorized Official First Name:
ANTHONY
Authorized Official Middle Name:
R
Authorized Official Title or Position:
CHIEF MEDICAL OFFICER
Authorized Official Telephone Number:
919-544-4097

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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