MEDICARE: MR. GORDON QUATLEBAUM SCOTT JR. OPTICIAN

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	156FX1800X	Optician	352	SC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1447387048
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. GORDON QUATLEBAUM SCOTT JR. OPTICIAN

Provider Business Mailing Address
First Line	:	411 COMMERCE DR NE
Second Line	:
City	:	COLUMBIA
State	:	SC
Zip	:	29223
Country	:	US
Telephone Number	:	803-254-9381
Fax Number	:	803-254-1978

Provider Business Practice Location Address
First Line	:	1812 WASHINGTON ST
Second Line	:
City	:	COLUMBIA
State	:	SC
Zip	:	29201-3549
Country	:	US
Telephone Number	:	803-254-9381
Fax Number	:	803-254-1978

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/28/2007
Last Update Date	:	07/09/2007

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