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General NPI Number Information
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NPI Number | 1699928309
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Entity Type | Organization
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Legal Business Name | OUTER VISION CORP 2
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Dates
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Enumeration Date | 10/25/2008
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Last Update Date | 10/28/2008
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Provider Practice Location Address
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Address Line | 1890 SAM RITTENBERG BLVD
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City | CHARLESTON
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State | SC
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Zip | 29407-4801
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Country | US
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Telephone | 843-763-2020
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Fax | 843-763-2021
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Provider Business Mailing Address
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Address Line | 1890 SAM RITTENBERG BLVD
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City | CHARLESTON
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State | SC
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Zip | 29407-4801
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Country | US
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Telephone | 843-763-2020
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Fax | 843-763-2021
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Authorized Official
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Title or Position | MANAGER/OPTICIAN
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Name | DONNIE ANDERSON
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Credential |
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Telephone | 843-763-2020
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 305R00000X
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Taxonomy Name | Preferred Provider Organization
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License Number | 6952
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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 | SC0551
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License Number State | SC
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