MEDICARE: NORTHSIDE VISION, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	1554	SC

General Provider Information

NPI Number	:	1184948150
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NORTHSIDE VISION, LLC

Provider Business Mailing Address
First Line	:	2603 BOILING SPRINGS RD
Second Line	:	SUITE B
City	:	BOILING SPRINGS
State	:	SC
Zip	:	29316-6011
Country	:	US
Telephone Number	:	864-578-3926
Fax Number	:

Provider Business Practice Location Address
First Line	:	2603 BOILING SPRINGS RD
Second Line	:	SUITE B
City	:	BOILING SPRINGS
State	:	SC
Zip	:	29316-6011
Country	:	US
Telephone Number	:	864-578-3926
Fax Number	:

Authorized Official
Title or Position	:	SOLE MEMBER
Name	:	MELISSA F. STILING
Credential	:	OD
Telephone Number	:	864-578-3926

Provider Enumeration Date	:	03/19/2010
Last Update Date	:	03/19/2010

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