1548329097 NPI number — ANGEL OAK EYE CENTER

Table of content: (NPI 1548329097)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548329097 NPI number — ANGEL OAK EYE CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ANGEL OAK EYE CENTER
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:
1548329097
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/27/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 874
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JOHNS ISLAND
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29457-0874
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
843-559-5333
Provider Business Mailing Address Fax Number:
843-559-5339

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2875 MAYBANK HWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JOHNS ISLAND
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29455-4808
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-559-5333
Provider Business Practice Location Address Fax Number:
843-559-5339
Provider Enumeration Date:
12/08/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BOHAC
Authorized Official First Name:
PAUL
Authorized Official Middle Name:
W
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
843-559-5333

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  907 , 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: DA9762 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: DO9070 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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