1053537068 NPI number — COASTAL EYE CARE OF CHARLESTON, LLC

Table of content: (NPI 1053537068)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053537068 NPI number — COASTAL EYE CARE OF CHARLESTON, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COASTAL EYE CARE OF CHARLESTON, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1053537068
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/15/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1606 HARBOR VIEW RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHARLESTON
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29412-3216
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
843-795-3937
Provider Business Mailing Address Fax Number:
843-795-4760

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1606 HARBOR VIEW RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHARLESTON
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29412-3216
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-795-3937
Provider Business Practice Location Address Fax Number:
843-795-4760
Provider Enumeration Date:
04/18/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
BROOKS
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
C
Authorized Official Title or Position:
OPTOMETRIST
Authorized Official Telephone Number:
843-795-3937

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  901 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 410025802 . This is a "RR MEDICARE" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: D09015 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".