Healthcare Provider Details

I. General information

NPI: 1093836124
Provider Name (Legal Business Name): SANSBURY EYE CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/03/2007
Last Update Date: 01/21/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7367 TWO NOTCH RD
COLUMBIA SC
29223-7619
US

IV. Provider business mailing address

7367 TWO NOTCH RD
COLUMBIA SC
29223-7619
US

V. Phone/Fax

Practice location:
  • Phone: 803-788-1335
  • Fax: 803-788-6954
Mailing address:
  • Phone: 803-788-1335
  • Fax: 803-788-6954

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156FX1800X
TaxonomyOptician
License Number204
License Number StateSC

VIII. Authorized Official

Name: MR. RAY A SANSBURY
Title or Position: CEO
Credential: OPTICIAN
Phone: 803-781-2123