Healthcare Provider Details

I. General information

NPI: 1023292166
Provider Name (Legal Business Name): DANIEL BRUCE GOSNELL OPTICIAN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/26/2007
Last Update Date: 12/26/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1946 AUGUSTA STREET
GREENVILLE SC
29605
US

IV. Provider business mailing address

1946 AUGUSTA STREET
GREENVILLE SC
29605
US

V. Phone/Fax

Practice location:
  • Phone: 864-233-4148
  • Fax: 864-233-3620
Mailing address:
  • Phone: 864-233-4148
  • Fax: 864-233-3620

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156FX1800X
TaxonomyOptician
License Number203
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: