Provider Demographics
NPI:1134156847
Name:TOWN CENTER VISION OPTOMETRISTS P.A.
Entity type:Organization
Organization Name:TOWN CENTER VISION OPTOMETRISTS P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:WILLIS
Authorized Official - Last Name:FRESHWATER
Authorized Official - Suffix:JR
Authorized Official - Credentials:OD
Authorized Official - Phone:336-712-4733
Mailing Address - Street 1:6270 TOWNCENTER DR
Mailing Address - Street 2:
Mailing Address - City:CLEMMONS
Mailing Address - State:NC
Mailing Address - Zip Code:27012-9376
Mailing Address - Country:US
Mailing Address - Phone:336-712-4733
Mailing Address - Fax:336-712-4704
Practice Address - Street 1:6270 TOWNCENTER DR
Practice Address - Street 2:
Practice Address - City:CLEMMONS
Practice Address - State:NC
Practice Address - Zip Code:27012-9376
Practice Address - Country:US
Practice Address - Phone:336-712-4733
Practice Address - Fax:336-712-4704
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-27
Last Update Date:2011-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1494152W00000X
NC1258152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2469546Medicare PIN
NC6490580001Medicare NSC