=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922327543
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ELECTRIC CITY EYE CARE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/21/2010
-----------------------------------------------------
Last Update Date | 05/21/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1807B E GREENVILLE ST
-----------------------------------------------------
City | ANDERSON
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29621-2034
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 864-245-9161
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 212 THOMAS WELBORN RD
-----------------------------------------------------
City | ANDERSON
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29625-6401
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DOUGLAS REED
-----------------------------------------------------
Credential | OD
-----------------------------------------------------
Telephone | 864-245-9161
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 1263
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------