Healthcare Provider Details

I. General information

NPI: 1689264699
Provider Name (Legal Business Name): SHIVANI PATEL OD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/23/2021
Last Update Date: 01/23/2021
Certification Date: 01/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9700 REDSTONE DR STE 300
INDIAN LAND SC
29707-5409
US

IV. Provider business mailing address

5020 WOODVIEW LN
WEDDINGTON NC
28104-8057
US

V. Phone/Fax

Practice location:
  • Phone: 803-548-3937
  • Fax:
Mailing address:
  • Phone: 864-940-6466
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2247
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: