Provider Demographics
NPI:1730363144
Name:LAKE NORMAN EYE OD PA
Entity type:Organization
Organization Name:LAKE NORMAN EYE OD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:S
Authorized Official - Last Name:HARRIS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:704-799-2233
Mailing Address - Street 1:548 WILLIAMSON RD STE 1
Mailing Address - Street 2:
Mailing Address - City:MOORESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28117-9111
Mailing Address - Country:US
Mailing Address - Phone:704-799-2233
Mailing Address - Fax:704-799-1567
Practice Address - Street 1:548 WILLIAMSON RD STE 1
Practice Address - Street 2:
Practice Address - City:MOORESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28117
Practice Address - Country:US
Practice Address - Phone:704-799-2233
Practice Address - Fax:704-799-1567
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-20
Last Update Date:2018-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCNC1589152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC890900TMedicaid
NC2348564Medicare PIN
NC890900TMedicaid