=====================================================
General NPI Number Information
=====================================================
NPI Number | 1316314669
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EDDIS OPHTHALMIC SERVICES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/21/2015
-----------------------------------------------------
Last Update Date | 08/21/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10136 TWO NOTCH RD SUITE 107D
-----------------------------------------------------
City | COLUMBIA
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29229-4389
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 803-760-7082
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10136 TWO NOTCH RD SUITE 107D
-----------------------------------------------------
City | COLUMBIA
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29229-4389
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 803-760-7082
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | MRS. ELIZABETH A FITE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 803-760-7082
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 1849
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------