1295713980 NPI number — MANTER OPTOMETRIC, LLC

Table of content: (NPI 1295713980)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295713980 NPI number — MANTER OPTOMETRIC, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MANTER OPTOMETRIC, 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:
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:
1295713980
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/16/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1057 BROAD ST STE 1
Provider Second Line Business Mailing Address:
SUMTER MALL
Provider Business Mailing Address City Name:
SUMTER
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29150-2567
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
803-775-7877
Provider Business Mailing Address Fax Number:
803-934-0547

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1057 BROAD ST STE 1
Provider Second Line Business Practice Location Address:
SUMTER MALL
Provider Business Practice Location Address City Name:
SUMTER
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29150-2567
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-775-7877
Provider Business Practice Location Address Fax Number:
803-934-0547
Provider Enumeration Date:
01/04/2006

Additional Information

Authorized Official

Authorized Official Last Name:
DEAN
Authorized Official First Name:
STEVEN
Authorized Official Middle Name:
K
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
803-775-7877

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: D11379 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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