Basic Information
| Provider Information | |||||||||
| NPI: | 1912034273 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BELKA | ||||||||
| FirstName: | LAURA | ||||||||
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| Credential: | OD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 119 LATONEA DR | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 292107572 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8037988642 | ||||||||
| FaxNumber: | 8037980422 | ||||||||
| Practice Location | |||||||||
| Address1: | 360 HARBISON BLVD | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 292122248 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8037328336 | ||||||||
| FaxNumber: | 8037322239 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/27/2007 | ||||||||
| LastUpdateDate: | 10/25/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 1429 | SC | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | D14296 | 05 | SC | MEDICAID |