Healthcare Provider Details

I. General information

NPI: 1023741279
Provider Name (Legal Business Name): SAMUEL JAY SIMON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2022
Last Update Date: 07/06/2022
Certification Date: 07/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1451 WOODRUFF RD
GREENVILLE SC
29607-5741
US

IV. Provider business mailing address

1451 WOODRUFF RD
GREENVILLE SC
29607-5741
US

V. Phone/Fax

Practice location:
  • Phone: 864-234-5616
  • Fax: 864-234-4996
Mailing address:
  • Phone: 864-234-5616
  • Fax: 864-234-4996

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156FX1800X
TaxonomyOptician
License Number685
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: