Healthcare Provider Details

I. General information

NPI: 1124409321
Provider Name (Legal Business Name): SANSBURY EYE CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/12/2015
Last Update Date: 06/13/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2313 N BELTLINE BLVD
COLUMBIA SC
29204-3416
US

IV. Provider business mailing address

2313 N BELTLINE BLVD
COLUMBIA SC
29204-3416
US

V. Phone/Fax

Practice location:
  • Phone: 803-788-1335
  • Fax: 803-749-0183
Mailing address:
  • Phone: 803-788-1335
  • Fax: 803-788-6954

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number204
License Number StateSC

VIII. Authorized Official

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