Organization
FRED S CLONINGER OD
Active
Parent organization
FRED S CLONINGER OD
Other names
Broad Street Vision Center
Organization subpart
Yes
Provider details
NPI number
Legal business name
FRED S CLONINGER OD
Authorized official
FRED S CLONINGER (OWNER)
70418653731
Entity
Organization
Contact information
Practice address
406 S BROAD ST, SUITE A, GASTONIA, NC 28054-4304
(704) 865-3731
(704) 864-5736
Mailing address
406 S BROAD ST, SUITE A, GASTONIA, NC 28054-4304
(704) 865-3731
(704) 864-5736
Taxonomy
Speciality
Code
Description
License number
State
332H00000X
Eyewear Supplier
Primary
0804
NC
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
8909163
—
NC
Enumeration date
08/29/2014
Last updated
08/29/2014
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