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General NPI Number Information
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NPI Number | 1609343227
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Entity Type | Organization
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Legal Business Name | FIVE FORKS VISION, LLC
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Dates
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Enumeration Date | 11/01/2018
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Last Update Date | 08/26/2019
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Provider Practice Location Address
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Address Line | 2827 WOODRUFF RD
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City | SIMPSONVILLE
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State | SC
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Zip | 29681-4807
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Country | US
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Telephone | 864-520-2480
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Fax |
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Provider Business Mailing Address
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Address Line | 2827 WOODRUFF RD
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City | SIMPSONVILLE
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State | SC
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Zip | 29681-4807
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Country | US
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Telephone | 864-520-2480
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Fax |
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Authorized Official
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Title or Position | OPTOMETRIST / OWNER
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Name | GORDON STANLEY JOHNSON
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Credential | OD
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Telephone | 864-520-2480
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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 |
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License Number State |
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