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General NPI Number Information
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NPI Number | 1912611971
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Entity Type | Organization
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Legal Business Name | PARK CIRCLE VISION LLC
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Dates
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Enumeration Date | 01/12/2023
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Last Update Date | 01/12/2023
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Provider Practice Location Address
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Address Line | 1816 SUCCESS ST STE 101
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City | NORTH CHARLESTON
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State | SC
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Zip | 29405-7851
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Country | US
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Telephone | 843-203-0200
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Fax | 843-203-5324
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Provider Business Mailing Address
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Address Line | 1816 SUCCESS ST STE 101
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City | NORTH CHARLESTON
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State | SC
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Zip | 29405-7851
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Country | US
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Telephone | 843-203-0200
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Fax |
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Authorized Official
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Title or Position | MEMBER
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Name | DR. JESSE WILLINGHAM
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Credential |
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Telephone | 843-203-0200
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152WV0400X
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Taxonomy Name | Vision Therapy Optometrist
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License Number |
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License Number State |
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