Provider Demographics
NPI:1730340860
Name:SID
Entity type:Organization
Organization Name:SID
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OD
Authorized Official - Prefix:DR
Authorized Official - First Name:SID
Authorized Official - Middle Name:
Authorized Official - Last Name:SPENCER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-368-4727
Mailing Address - Street 1:118 GOLF COURSE RD
Mailing Address - Street 2:
Mailing Address - City:PILOT MOUNTAIN
Mailing Address - State:NC
Mailing Address - Zip Code:27041-8410
Mailing Address - Country:US
Mailing Address - Phone:336-368-4727
Mailing Address - Fax:336-368-5627
Practice Address - Street 1:118 GOLF COURSE RD
Practice Address - Street 2:
Practice Address - City:PILOT MOUNTAIN
Practice Address - State:NC
Practice Address - Zip Code:27041-8410
Practice Address - Country:US
Practice Address - Phone:336-368-4727
Practice Address - Fax:336-368-5627
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-20
Last Update Date:2008-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0951332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier