Healthcare Provider Details

I. General information

NPI: 1508853904
Provider Name (Legal Business Name): CHAD A CARLSSON OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/30/2005
Last Update Date: 09/10/2026
Certification Date: 09/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3911 MAIN ST
LORIS SC
29569-3017
US

IV. Provider business mailing address

PO BOX 11407
BIRMINGHAM AL
35246-8575
US

V. Phone/Fax

Practice location:
  • Phone: 864-654-6706
  • Fax: 843-756-6667
Mailing address:
  • Phone: 864-359-1308
  • Fax: 239-496-3939

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2242
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: