NPIMap

Organization Active NPI

Fred S Cloninger OD

Doing business as Broad Street Vision Center

  • Eyewear Supplier
  • Gastonia, NC
National Provider Identifier
1235539099
Registry record updated Aug 29, 2014
On this page

Key facts

NPPES NPI Registry
Primary specialty
Eyewear SupplierTaxonomy code 332H00000X
License
0804 Issued in NC
Legal business name
FRED S CLONINGER OD
Doing business as
Broad Street Vision Center
Practice address
406 S Broad St
Suite a
Gastonia, NC 28054-4304
Phone
(704) 865-3731
Fax
(704) 864-5736
NPI assigned
Aug 29, 2014
Last updated
Aug 29, 2014By the provider in NPPES
Organization subpart
Yes
Parent organization
FRED S CLONINGER ODAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Aug 29, 2014

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Fred S CloningerNPI 1508965161
Title
Owner
Phone
70418653731

Authorized official NPPES reports the official by name only. The link goes to the one practitioner with that name whose NPPES practice address or phone number is this organization’s.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Eyewear Supplier 332H00000X 0804 NC Primary

Addresses

Primary practice location

406 S Broad St
Suite a
Gastonia, NC 28054-4304

Mailing address

406 S Broad St
Suite a
Gastonia, NC 28054-4304
Phone (704) 865-3731

Other identifiers 1

IdentifierTypeStateIssuer
8909163MedicaidNC

Other names 1

  • Broad Street Vision Center Doing business as

National Provider Directory

National Provider Directory
Part of
Fred S Cloninger OD

Practitioners & affiliated clinicians

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1409270400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1409270400000",
    "number": "1235539099",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "406 S BROAD ST",
            "address_2": "SUITE A",
            "city": "GASTONIA",
            "state": "NC",
            "postal_code": "280544304",
            "telephone_number": "704-865-3731",
            "fax_number": "704-864-5736"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "406 S BROAD ST",
            "address_2": "SUITE A",
            "city": "GASTONIA",
            "state": "NC",
            "postal_code": "280544304",
            "telephone_number": "704-865-3731",
            "fax_number": "704-864-5736"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "FRED S CLONINGER OD",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "FRED S CLONINGER OD",
        "enumeration_date": "2014-08-29",
        "last_updated": "2014-08-29",
        "status": "A",
        "authorized_official_last_name": "CLONINGER",
        "authorized_official_first_name": "FRED",
        "authorized_official_middle_name": "S",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "70418653731"
    },
    "taxonomies": [
        {
            "code": "332H00000X",
            "taxonomy_group": "",
            "desc": "Eyewear Supplier",
            "state": "NC",
            "license": "0804",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "8909163",
            "state": "NC"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Broad Street Vision Center",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Gastonia, NC

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 29, 2014; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.