Healthcare Provider Details

I. General information

NPI: 1306256003
Provider Name (Legal Business Name): ELLESSE KEEFER O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/02/2014
Last Update Date: 10/02/2026
Certification Date: 10/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

735 JOHNNIE DODDS BLVD STE 101
MT PLEASANT SC
29464-3060
US

IV. Provider business mailing address

735 JOHNNIE DODDS BLVD STE 101
MOUNT PLEASANT SC
29464-3060
US

V. Phone/Fax

Practice location:
  • Phone: 843-592-3955
  • Fax:
Mailing address:
  • Phone: 843-592-3955
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1857
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: