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General NPI Number Information
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NPI Number | 1184009540
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Entity Type | Organization
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Legal Business Name | JOHANSEN PRECISION EYE CARE LLC
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Dates
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Enumeration Date | 07/28/2015
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Last Update Date | 08/30/2023
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Provider Practice Location Address
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Address Line | 214 WALLER AVE
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City | GREENWOOD
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State | SC
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Zip | 29646-2747
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Country | US
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Telephone | 864-543-3939
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Fax | 864-538-6284
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Provider Business Mailing Address
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Address Line | PO BOX 238
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City | NINETY SIX
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State | SC
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Zip | 29666-0238
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Country | US
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Telephone | 864-223-6062
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Fax | 864-538-6284
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Authorized Official
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Title or Position | OWNER
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Name | DR. SAMUEL LEE JOHANSEN
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Credential | O.D.
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Telephone | 864-992-6386
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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 | 1872
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License Number State | SC
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