Provider Demographics
NPI:1023112646
Name:CAPE FEAR OPTOMETRIC CLINIC PA
Entity type:Organization
Organization Name:CAPE FEAR OPTOMETRIC CLINIC PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHELE
Authorized Official - Middle Name:PHILBRICK
Authorized Official - Last Name:KEEL
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:704-694-3618
Mailing Address - Street 1:1134 HOLLY ST
Mailing Address - Street 2:
Mailing Address - City:WADESBORO
Mailing Address - State:NC
Mailing Address - Zip Code:28170-2452
Mailing Address - Country:US
Mailing Address - Phone:704-694-3618
Mailing Address - Fax:
Practice Address - Street 1:1134 HOLLY ST
Practice Address - Street 2:
Practice Address - City:WADESBORO
Practice Address - State:NC
Practice Address - Zip Code:28170-2452
Practice Address - Country:US
Practice Address - Phone:704-694-3618
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-12
Last Update Date:2008-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCNC1462152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC890905BMedicaid
NC0905BOtherBLUE CROSS BLUE SHIELD
NC890903CMedicaid
NC890905BMedicaid
NC2468684Medicare ID - Type Unspecified
NC0905BOtherBLUE CROSS BLUE SHIELD
NC890903CMedicaid