Healthcare Provider Details

I. General information

NPI: 1457707911
Provider Name (Legal Business Name): RYAN SHAKE O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/13/2016
Last Update Date: 05/13/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2000 COASTAL GRAND CIR
MYRTLE BEACH SC
29577-9798
US

IV. Provider business mailing address

2000 COASTAL GRAND CIR
MYRTLE BEACH SC
29577-9798
US

V. Phone/Fax

Practice location:
  • Phone: 843-444-0900
  • Fax:
Mailing address:
  • Phone: 843-444-0900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberSC1934
License Number StateSC

VII. Legacy identifiers

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: