=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811105877
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SUSAN ANDERSON MULLINS LICENSED OPTICIAN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/21/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7685 NORTHWOODS BLVD SUITE 8 F
-----------------------------------------------------
City | NORTH CHARLESTON
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29406-4002
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-797-2090
-----------------------------------------------------
Fax | 843-797-3822
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 145 ANDREWS BLVD
-----------------------------------------------------
City | SUMMERVILLE
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29483-8606
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-871-8195
-----------------------------------------------------
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 | 421
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------