Healthcare Provider Details

I. General information

NPI: 1376856831
Provider Name (Legal Business Name): MICHAEL DESAUTELS OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2010
Last Update Date: 07/26/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5580 FOREST DR STE. 118
COLUMBIA SC
29206-5000
US

IV. Provider business mailing address

5580 FOREST DR STE. 118
COLUMBIA SC
29206-5000
US

V. Phone/Fax

Practice location:
  • Phone: 803-678-4662
  • Fax: 803-678-4667
Mailing address:
  • Phone: 803-678-4662
  • Fax: 803-678-4667

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1607
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: