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General NPI Number Information
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NPI Number | 1184719387
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Entity Type | Organization
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Legal Business Name | JACKSON DAVENPORT VISION, INC.
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Dates
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Enumeration Date | 10/04/2006
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Last Update Date | 08/07/2023
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Provider Practice Location Address
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Address Line | 218 OLD TROLLEY RD
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City | SUMMERVILLE
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State | SC
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Zip | 29485-4929
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Country | US
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Telephone | 843-871-9750
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Fax | 843-873-6197
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Provider Business Mailing Address
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Address Line | 218 OLD TROLLEY RD
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City | SUMMERVILLE
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State | SC
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Zip | 29485-4929
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Country | US
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Telephone | 843-871-9750
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Fax | 843-873-6197
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Authorized Official
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Title or Position | PRESIDENT
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Name | MR. KENNETH RICHARD DAVENPORT II
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Credential |
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Telephone | 843-871-9750
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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 | 589
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License Number State | SC
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Taxonomy #2
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Taxonomy Code | 156FX1800X
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Taxonomy Name | Optician
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License Number | 686
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License Number State | SC
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Taxonomy #3
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number |
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License Number State |
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