Healthcare Provider Details

I. General information

NPI: 1154618528
Provider Name (Legal Business Name): JENNIFER V SEIBERT OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MS. JENNIFER MARIA VIRAG

II. Dates (important events)

Enumeration Date: 07/06/2011
Last Update Date: 12/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1057 BROAD ST #48
SUMTER SC
29150-2567
US

IV. Provider business mailing address

3490 DAMASCUS CHURCH RD
CAMDEN SC
29020-9188
US

V. Phone/Fax

Practice location:
  • Phone: 803-775-8951
  • Fax: 803-775-8955
Mailing address:
  • Phone: 864-650-4515
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2011020051
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License Number2011020051
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code152WV0400X
TaxonomyVision Therapy Optometrist
License Number2011020051
License Number StateMO
# 4
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1717
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: