=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922537232
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DR. SARA BEAVER, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/08/2017
-----------------------------------------------------
Last Update Date | 11/08/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 204 LANGFORD RD
-----------------------------------------------------
City | BLYTHEWOOD
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29016-8648
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 803-714-1116
-----------------------------------------------------
Fax | 803-714-1162
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 204 LANGFORD RD
-----------------------------------------------------
City | BLYTHEWOOD
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29016-8648
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 803-714-1116
-----------------------------------------------------
Fax | 803-714-1162
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. SARA BEAVER
-----------------------------------------------------
Credential | OD
-----------------------------------------------------
Telephone | 803-714-1116
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------