Healthcare Provider Details

I. General information

NPI: 1033802806
Provider Name (Legal Business Name): ELENA VANSANT MARTIN OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/30/2023
Last Update Date: 05/30/2023
Certification Date: 05/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3618 SUNSET BLVD STE A
WEST COLUMBIA SC
29169-3046
US

IV. Provider business mailing address

101 SALUDA POINTE DR UNIT 415
LEXINGTON SC
29072-7060
US

V. Phone/Fax

Practice location:
  • Phone: 803-732-4099
  • Fax:
Mailing address:
  • Phone: 803-920-3798
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2403
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: