Healthcare Provider Details

I. General information

NPI: 1578759908
Provider Name (Legal Business Name): 20/20 EYEWEAR INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/19/2007
Last Update Date: 07/20/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12060 HIGHWAY 17 BYP UNIT B
MURRELLS INLET SC
29576-9401
US

IV. Provider business mailing address

12060 HIGHWAY 17 BYP UNIT B
MURRELLS INLET SC
29576-9401
US

V. Phone/Fax

Practice location:
  • Phone: 843-357-2020
  • Fax: 843-357-2021
Mailing address:
  • Phone: 843-357-2020
  • Fax: 843-357-2021

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number713
License Number StateSC

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: MR. JOHN BLAIR FOWLER
Title or Position: OWNER
Credential:
Phone: 18433572020