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General NPI Number Information
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NPI Number | 1376647396
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Entity Type | Individual
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Provider Name | NICKOLAS ANDREW VASTIS O.D.
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Gender | Male
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Dates
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Enumeration Date | 09/11/2006
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Last Update Date | 09/11/2012
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Provider Practice Location Address
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Address Line | 350 HARBISON BLVD
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City | COLUMBIA
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State | SC
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Zip | 29212-2248
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Country | US
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Telephone | 803-749-6878
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Fax |
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Provider Business Mailing Address
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Address Line | 627 CRESTMONT RD
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City | COLUMBIA
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State | SC
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Zip | 29229-7027
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Country | US
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Telephone | 803-699-5110
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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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 | 1423
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License Number State | SC
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