=====================================================
General NPI Number Information
=====================================================
NPI Number | 1801682414
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TERRELL THOMAS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/18/2025
-----------------------------------------------------
Last Update Date | 04/18/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 900 WEST HIGHWAY 52
-----------------------------------------------------
City | LAKE CITY
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29560
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-394-7626
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2222 W PICCADILLY DR
-----------------------------------------------------
City | FLORENCE
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29501-6156
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-616-0730
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 156FX1800X
-----------------------------------------------------
Taxonomy Name | Optician
-----------------------------------------------------
License Number | 1506
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------