MEDICARE: GRAND STRAND VISION SERVICES, INC.

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	152WV0400X	Vision Therapy Optometrist

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1942226337
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GRAND STRAND VISION SERVICES, INC.

Provider Business Mailing Address
First Line	:	4886 SOCASTEE BLVD
Second Line	:
City	:	MYRTLE BEACH
State	:	SC
Zip	:	29588-7245
Country	:	US
Telephone Number	:	843-293-1555
Fax Number	:	843-293-8102

Provider Business Practice Location Address
First Line	:	4886 SOCASTEE BLVD
Second Line	:
City	:	MYRTLE BEACH
State	:	SC
Zip	:	29588-7245
Country	:	US
Telephone Number	:	843-293-1555
Fax Number	:	843-293-8102

Authorized Official
Title or Position	:	OWNER
Name	:	DR. MARK TRACY DEAN
Credential	:	OD
Telephone Number	:	843-293-1555

Provider Enumeration Date	:	07/15/2006
Last Update Date	:	10/16/2011

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