Provider Demographics
NPI:1194895805
Name:BRANCH & STAFFORD OPTOMETRIC ASSOCIATES, PA
Entity type:Organization
Organization Name:BRANCH & STAFFORD OPTOMETRIC ASSOCIATES, PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:BRANCH
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:803-781-2212
Mailing Address - Street 1:PO BOX 493
Mailing Address - Street 2:
Mailing Address - City:NEWBERRY
Mailing Address - State:SC
Mailing Address - Zip Code:29108-0493
Mailing Address - Country:US
Mailing Address - Phone:803-276-3271
Mailing Address - Fax:803-233-2881
Practice Address - Street 1:2737 WINNSBORO RD
Practice Address - Street 2:
Practice Address - City:NEWBERRY
Practice Address - State:SC
Practice Address - Zip Code:29108-4011
Practice Address - Country:US
Practice Address - Phone:803-276-3271
Practice Address - Fax:803-233-2881
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-09
Last Update Date:2013-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC609,696,496,1336152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCPC2519Medicaid
SC2929Medicare PIN
SCC14663Medicare PIN
SCPC2519Medicaid