Healthcare Provider Details

I. General information

NPI: 1417581638
Provider Name (Legal Business Name): SOUTH CAROLINA RETINA INSTITUTE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/26/2020
Last Update Date: 09/11/2020
Certification Date: 09/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1404 MAIN ST
CONWAY SC
29526-3567
US

IV. Provider business mailing address

1404 MAIN ST
CONWAY SC
29526-3567
US

V. Phone/Fax

Practice location:
  • Phone: 205-907-3912
  • Fax:
Mailing address:
  • Phone: 843-488-1100
  • Fax: 843-488-7701

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207WX0107X
TaxonomyRetina Specialist (Ophthalmology) Physician
License Number
License Number State

VIII. Authorized Official

Name: NICHOLAS D MARCHASE
Title or Position: OWNER
Credential: MD
Phone: 205-907-3912