1285616037 NPI number — CAROLINA CATARACT CLINIC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285616037 NPI number — CAROLINA CATARACT CLINIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CAROLINA CATARACT CLINIC
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:
ADVANTAGE EYE CARE
Provider Other Organization Name Type Code:
3
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:
1285616037
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/03/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 23098
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COLUMBIA
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29224-3098
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
803-788-2276
Provider Business Mailing Address Fax Number:
803-788-1022

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
115 ATRIUM WAY
Provider Second Line Business Practice Location Address:
SUITE 120
Provider Business Practice Location Address City Name:
COLUMBIA
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29223
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-788-2276
Provider Business Practice Location Address Fax Number:
803-788-1022
Provider Enumeration Date:
11/17/2005

Additional Information

Authorized Official

Authorized Official Last Name:
JACOBS
Authorized Official First Name:
DEAN
Authorized Official Middle Name:
ROBERT
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
803-788-2276

Provider Taxonomy Codes

  • Taxonomy code: 207W00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 125705 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: GP0041 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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