Healthcare Provider Details

I. General information

NPI: 1134309263
Provider Name (Legal Business Name): PROFESSIONAL OPTICAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/06/2007
Last Update Date: 06/06/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2270 ASHLEY CROSSING DR STE 100
CHARLESTON SC
29414-5749
US

IV. Provider business mailing address

2270 ASHLEY CROSSING DR STE 100
CHARLESTON SC
29414-5749
US

V. Phone/Fax

Practice location:
  • Phone: 843-571-3967
  • Fax:
Mailing address:
  • Phone: 843-571-3967
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156FX1800X
TaxonomyOptician
License Number
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number
License Number StateSC

VIII. Authorized Official

Name: JOHN KULZE
Title or Position: PHYSICIAN
Credential: MD
Phone: 843-556-2357