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General NPI Number Information
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NPI Number | 1043513542
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Entity Type | Organization
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Legal Business Name | PALMETTO STATE EYECARE, LLC
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Dates
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Enumeration Date | 12/06/2010
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Last Update Date | 12/06/2010
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Provider Practice Location Address
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Address Line | 5426 FOREST DR
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City | COLUMBIA
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State | SC
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Zip | 29206-5401
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Country | US
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Telephone | 803-767-9964
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Fax | 803-790-2163
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Provider Business Mailing Address
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Address Line | 244 LOTHROP HILL RD
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City | LEXINGTON
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State | SC
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Zip | 29072-7747
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Country | US
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Telephone | 920-915-3422
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Fax |
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Authorized Official
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Title or Position | OWNER/OPTOMETRIST
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Name | DR. FERINE N. JOHANNES
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Credential | O.D.
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Telephone | 920-915-3422
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 1568
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License Number State | SC
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