Healthcare Provider Details

I. General information

NPI: 1700469772
Provider Name (Legal Business Name): EMILY DORAN RETTEW OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/28/2021
Last Update Date: 09/10/2021
Certification Date: 09/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

702 CROSS HILL RD STE 200A
COLUMBIA SC
29205-2084
US

IV. Provider business mailing address

5126 GRANDVIEW DR
FORT MILL SC
29707-5858
US

V. Phone/Fax

Practice location:
  • Phone: 803-790-0000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2264
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: