Basic Information
| Provider Information | |||||||||
| NPI: | 1407066905 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | OPTICAL IMPRESSIONS, A LIMITED LIABILITY CORPORATION | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8096 RIVERS AVE STE A | ||||||||
| Address2: | |||||||||
| City: | NORTH CHARLESTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294069243 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8438182020 | ||||||||
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| Practice Location | |||||||||
| Address1: | 8096 RIVERS AVE STE A | ||||||||
| Address2: | |||||||||
| City: | NORTH CHARLESTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294069243 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8438182020 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2007 | ||||||||
| LastUpdateDate: | 01/02/2020 | ||||||||
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| AuthorizedOfficialLastName: | RICHARD | ||||||||
| AuthorizedOfficialFirstName: | LAWRENCE | ||||||||
| AuthorizedOfficialMiddleName: | EDWIN | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8438182020 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | 01/02/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | N | 193200000X MULTI-SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist | 332H00000X | N | Suppliers | Eyewear Supplier (Equipment, not the service) | 156FX1800X | Y | 193200000X MULTI-SPECIALTY GROUP | Eye and Vision Services Providers | Technician/Technologist | Optician |
No ID Information.