Healthcare Provider Details

I. General information

NPI: 1972756682
Provider Name (Legal Business Name): OUTER VISION CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/25/2008
Last Update Date: 10/25/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6185 RIVERS AVE STE G
NORTH CHARLESTON SC
29406-4999
US

IV. Provider business mailing address

6185 RIVERS AVE STE G
NORTH CHARLESTON SC
29406-4999
US

V. Phone/Fax

Practice location:
  • Phone: 843-572-7800
  • Fax: 843-572-7801
Mailing address:
  • Phone: 843-572-7800
  • Fax: 843-572-7801

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156FX1800X
TaxonomyOptician
License NumberSC0551
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code305R00000X
TaxonomyPreferred Provider Organization
License Number1997-03227
License Number StateSC

VIII. Authorized Official

Name: DONALD ANDERSON
Title or Position: MANAGER/OPTICIAN
Credential:
Phone: 843-572-7800