=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770920548
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | IN FOCUS EYE CARE INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/03/2013
-----------------------------------------------------
Last Update Date | 06/03/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1326 BUSH RIVER RD
-----------------------------------------------------
City | COLUMBIA
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29210-6804
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 803-790-1849
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | P O BOX 333
-----------------------------------------------------
City | BLYTHEWOOD
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29016-0614
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 803-790-1849
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. PETER CANDELA
-----------------------------------------------------
Credential | O.D.
-----------------------------------------------------
Telephone | 803-790-1849
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------