MEDICARE: PALMETTO STATE EYECARE, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	1568	SC

General Provider Information

NPI Number	:	1043513542
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PALMETTO STATE EYECARE, LLC

Provider Business Mailing Address
First Line	:	244 LOTHROP HILL RD
Second Line	:
City	:	LEXINGTON
State	:	SC
Zip	:	29072-7747
Country	:	US
Telephone Number	:	920-915-3422
Fax Number	:

Provider Business Practice Location Address
First Line	:	5426 FOREST DR
Second Line	:
City	:	COLUMBIA
State	:	SC
Zip	:	29206-5401
Country	:	US
Telephone Number	:	803-767-9964
Fax Number	:	803-790-2163

Authorized Official
Title or Position	:	OWNER/OPTOMETRIST
Name	:	DR. FERINE N. JOHANNES
Credential	:	O.D.
Telephone Number	:	920-915-3422

Provider Enumeration Date	:	12/06/2010
Last Update Date	:	12/06/2010

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