MEDICARE: POOLE FAMILY EYE CARE OF SIMPSONVILLE

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	1971	SC
2	152W00000X	Optometrist	1731	SC
3	152W00000X	Optometrist	539	SC
4	152W00000X	Optometrist	1414	SC

General Provider Information

NPI Number	:	1750752150
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	POOLE FAMILY EYE CARE OF SIMPSONVILLE

Provider Business Mailing Address
First Line	:	PO BOX 80927
Second Line	:
City	:	SIMPSONVILLE
State	:	SC
Zip	:	29680-0016
Country	:	US
Telephone Number	:	864-436-1234
Fax Number	:	864-967-7319

Provider Business Practice Location Address
First Line	:	419 SE MAIN ST
Second Line	:	STE 301
City	:	SIMPSONVILLE
State	:	SC
Zip	:	29681-2673
Country	:	US
Telephone Number	:	864-436-1234
Fax Number	:	864-963-7319

Authorized Official
Title or Position	:	MANAGING MEMBER
Name	:	DR. BRIAN J. POOLE
Credential	:	D.O.
Telephone Number	:	864-680-3037

Provider Enumeration Date	:	10/12/2015
Last Update Date	:	10/12/2015

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