Healthcare Provider Details

I. General information

NPI: 1649331547
Provider Name (Legal Business Name): SUSAN BOINEAU OPTICIAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/13/2006
Last Update Date: 11/05/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7610 HIGHWAY 164
HOLLYWOOD SC
29449-5934
US

IV. Provider business mailing address

PO BOX 38
ADAMS RUN SC
29426-0038
US

V. Phone/Fax

Practice location:
  • Phone: 843-889-9366
  • Fax: 843-889-9940
Mailing address:
  • Phone: 843-889-9366
  • Fax: 843-889-9940

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156F00000X
TaxonomyTechnician/Technologist
License Number730
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code247200000X
TaxonomyOther Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: