1558448001 NPI number — EAST COAST OPTOMETRIC, INC.

Table of content: (NPI 1558448001)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558448001 NPI number — EAST COAST OPTOMETRIC, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EAST COAST OPTOMETRIC, 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:
1558448001
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/12/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7539 GARNERS FERRY RD.
Provider Second Line Business Mailing Address:
EAST COAST OPTOMETRIC, INC.
Provider Business Mailing Address City Name:
COLUMBIA
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29209
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
803-779-9313
Provider Business Mailing Address Fax Number:
803-779-9551

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2209 WEST DEKALB ST.
Provider Second Line Business Practice Location Address:
H. RUBIN VISION CENTER
Provider Business Practice Location Address City Name:
CAMDEN
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29020
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-424-2020
Provider Business Practice Location Address Fax Number:
803-424-0952
Provider Enumeration Date:
11/01/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WEBBER
Authorized Official First Name:
KENNETH
Authorized Official Middle Name:
M
Authorized Official Title or Position:
COO
Authorized Official Telephone Number:
803-788-8204

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  1423 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 152W00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: DA9957 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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