1114908092 NPI number — GOOSE CREEK VISION CENTER, INC.

Table of content: (NPI 1114908092)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114908092 NPI number — GOOSE CREEK VISION CENTER, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GOOSE CREEK VISION CENTER, INC.
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:
6
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:
1114908092
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/24/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
425 REDBANK RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GOOSE CREEK
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29445-4505
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
843-797-1264
Provider Business Mailing Address Fax Number:
843-764-3602

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
425 REDBANK RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GOOSE CREEK
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29445-4505
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-797-1264
Provider Business Practice Location Address Fax Number:
843-764-3602
Provider Enumeration Date:
11/08/2005

Additional Information

Authorized Official

Authorized Official Last Name:
WATSKY
Authorized Official First Name:
MELVIN
Authorized Official Middle Name:
B.
Authorized Official Title or Position:
OPTOMETRIST
Authorized Official Telephone Number:
843-797-1264

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  SC568 , 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: DA9765 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: WA260115 . This is a "HIGHMARK BC/BS GROUP #" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com