1962954594 NPI number — CLAYTON DAVIS, OD OF SOUTH CAROLINA, 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 1962954594 NPI number — CLAYTON DAVIS, OD OF SOUTH CAROLINA, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CLAYTON DAVIS, OD OF SOUTH CAROLINA, 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:
1962954594
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/14/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1206 MOSER DR # 711
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MYRTLE BEACH
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29577-1575
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
806-778-9074
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
200 N BELTLINE DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FLORENCE
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29501-7403
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-662-2769
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/31/2016

Additional Information

Authorized Official

Authorized Official Last Name:
DAVIS
Authorized Official First Name:
CLAYTON
Authorized Official Middle Name:
Authorized Official Title or Position:
OPTOMETRY
Authorized Official Telephone Number:
806-778-9074

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  1870 , 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)





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