1063536142 NPI number — MRS. VICKI W CHAMBERLAIN OPTICIAN

Table of content: MRS. VICKI W CHAMBERLAIN OPTICIAN (NPI 1063536142)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063536142 NPI number — MRS. VICKI W CHAMBERLAIN OPTICIAN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CHAMBERLAIN
Provider First Name:
VICKI
Provider Middle Name:
W
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
OPTICIAN
Provider Gender Code:
F

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:
1063536142
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
217 ST. JAMES AVENUE
Provider Second Line Business Mailing Address:
STE. A5
Provider Business Mailing Address City Name:
GOOSE CREEK
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29445
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
843-797-5711
Provider Business Mailing Address Fax Number:
843-797-5712

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
217 SAINT JAMES AVE
Provider Second Line Business Practice Location Address:
STE. A5
Provider Business Practice Location Address City Name:
GOOSE CREEK
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29445-2938
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-797-5711
Provider Business Practice Location Address Fax Number:
843-797-5712
Provider Enumeration Date:
03/16/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 156FX1100X , with the licence number:  535 , 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: DV5352 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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