Healthcare Provider Details

I. General information

NPI: 1801809454
Provider Name (Legal Business Name): MONIE B CLIFTON O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/14/2006
Last Update Date: 02/26/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

439 CHANNEL ROAD SUITE #103
LAKE WYLIE SC
29710
US

IV. Provider business mailing address

439 CHANNEL ROAD SUITE #103
LAKE WYLIE SC
29710
US

V. Phone/Fax

Practice location:
  • Phone: 803-746-7711
  • Fax: 803-746-7189
Mailing address:
  • Phone: 803-746-7711
  • Fax: 803-746-7189

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2005000535
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1447
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: