Provider Demographics
NPI:1063536142
Name:CHAMBERLAIN, VICKI W (OPTICIAN)
Entity type:Individual
Prefix:MRS
First Name:VICKI
Middle Name:W
Last Name:CHAMBERLAIN
Suffix:
Gender:F
Credentials:OPTICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:217 ST. JAMES AVENUE
Mailing Address - Street 2:STE. A5
Mailing Address - City:GOOSE CREEK
Mailing Address - State:SC
Mailing Address - Zip Code:29445
Mailing Address - Country:US
Mailing Address - Phone:843-797-5711
Mailing Address - Fax:843-797-5712
Practice Address - Street 1:217 SAINT JAMES AVE
Practice Address - Street 2:STE. A5
Practice Address - City:GOOSE CREEK
Practice Address - State:SC
Practice Address - Zip Code:29445-2938
Practice Address - Country:US
Practice Address - Phone:843-797-5711
Practice Address - Fax:843-797-5712
Is Sole Proprietor?:No
Enumeration Date:2007-03-16
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC535156FX1100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1100XEye and Vision Services ProvidersTechnician/TechnologistOphthalmic
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCDV5352Medicaid