Healthcare Provider Details

I. General information

NPI: 1265476584
Provider Name (Legal Business Name): MONTGOMERY & RIDDLE EYECARE, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/16/2006
Last Update Date: 03/15/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22995 HIGHWAY 76 E
CLINTON SC
29325-7529
US

IV. Provider business mailing address

22995 HIGHWAY 76 E
CLINTON SC
29325-7529
US

V. Phone/Fax

Practice location:
  • Phone: 864-833-0038
  • Fax: 864-833-0520
Mailing address:
  • Phone: 864-833-0038
  • Fax: 864-833-0520

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. SAMUEL JACOB MONTGOMERY JR.
Title or Position: PRESIDENT
Credential: M.D.
Phone: 864-833-0038