1962775817 NPI number — WESTSIDE OPTICAL SHOP,LLC

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 1962775817 NPI number — WESTSIDE OPTICAL SHOP,LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WESTSIDE OPTICAL SHOP,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:
1962775817
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/31/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1413 JOHN B WHITE SR BLVD
Provider Second Line Business Mailing Address:
SUITE A
Provider Business Mailing Address City Name:
SPARTANBURG
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29306-3995
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
864-587-1039
Provider Business Mailing Address Fax Number:
864-587-1936

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1413 JOHN B WHITE SR BLVD
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
SPARTANBURG
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29306-3995
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
864-587-1039
Provider Business Practice Location Address Fax Number:
864-587-1936
Provider Enumeration Date:
02/22/2012

Additional Information

Authorized Official

Authorized Official Last Name:
ROEL
Authorized Official First Name:
LAWRENCE
Authorized Official Middle Name:
EDMUND
Authorized Official Title or Position:
OWNER/PROVIDER
Authorized Official Telephone Number:
864-542-1308

Provider Taxonomy Codes

  • Taxonomy code: 332H00000X , with the licence number:  120021119 , 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: 1164472098 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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