=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700931979
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CAROLINA GLAUCOMA AND VISION CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/25/2007
-----------------------------------------------------
Last Update Date | 09/09/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1 RICHLAND MEDICAL PARK DR SUITE 210
-----------------------------------------------------
City | COLUMBIA
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29203-6834
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 803-789-4144
-----------------------------------------------------
Fax | 803-779-4146
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1 RICHLAND MEDICAL PARK DR SUITE 210
-----------------------------------------------------
City | COLUMBIA
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29203-6834
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 803-789-4144
-----------------------------------------------------
Fax | 803-779-4146
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. ALRIC CHRISTOPHER BLAKE
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 803-779-4144
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207W00000X
-----------------------------------------------------
Taxonomy Name | Ophthalmology Physician
-----------------------------------------------------
License Number | 17330
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------