Healthcare Provider Details

I. General information

NPI: 1497718555
Provider Name (Legal Business Name): KIMBERLY DAWN STONEBURNER LICENSED OPTICIAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KIMBERLY DAWN MOORE LICENSED OPTICIAN

II. Dates (important events)

Enumeration Date: 04/10/2006
Last Update Date: 02/08/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

447 SOUTH RAILROAD AVE.
RIDGEVILLE SC
29472
US

IV. Provider business mailing address

742 NANCYS PL
RIDGEVILLE SC
29472-7000
US

V. Phone/Fax

Practice location:
  • Phone: 843-452-4140
  • Fax: 843-688-4192
Mailing address:
  • Phone: 843-452-4140
  • Fax: 843-688-4192

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156FX1800X
TaxonomyOptician
License Number717
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: