Healthcare Provider Details

I. General information

NPI: 1528848405
Provider Name (Legal Business Name): VITAL EYES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/29/2023
Last Update Date: 09/17/2024
Certification Date: 09/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

223 COLUMBIA AVE STE B
CHAPIN SC
29036
US

IV. Provider business mailing address

PO BOX 496
BALLENTINE SC
29002-0496
US

V. Phone/Fax

Practice location:
  • Phone: 803-930-0036
  • Fax: 833-722-0272
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: DR. ELISABETH J LAWSON
Title or Position: CO-OWNER
Credential: OD
Phone: 803-930-0036