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General NPI Number Information
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NPI Number | 1649321647
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Entity Type | Organization
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Legal Business Name | CUSTOM EYES VISION CARE INC
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Dates
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Enumeration Date | 01/16/2007
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Last Update Date | 07/17/2020
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Provider Practice Location Address
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Address Line | 7400 RIVERS AVE
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City | NORTH CHARLESTON
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State | SC
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Zip | 29406-4644
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Country | US
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Telephone | 843-824-2424
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Fax |
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Provider Business Mailing Address
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Address Line | 53 NORVIEW DR
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City | CHARLESTON
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State | SC
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Zip | 29407-3714
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Country | US
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Telephone | 843-824-2424
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Fax | 844-394-2068
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Authorized Official
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Title or Position | OPTOMETRIST
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Name | LINDA REYNOLDS
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Credential | O.D.
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Telephone | 843-824-2424
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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 | 1229
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License Number State | SC
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