Healthcare Provider Details

I. General information

NPI: 1902357791
Provider Name (Legal Business Name): BOSTON PERKINS O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/17/2016
Last Update Date: 10/17/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1945 W PALMETTO ST SUITE 111
FLORENCE SC
29501-3919
US

IV. Provider business mailing address

1945 W PALMETTO ST SUITE 111
FLORENCE SC
29501-3919
US

V. Phone/Fax

Practice location:
  • Phone: 843-679-1812
  • Fax:
Mailing address:
  • Phone: 843-679-1812
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number1968
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: