Provider Demographics
NPI:1215140793
Name:LORIS EYE ASSOCIATES PC
Entity type:Organization
Organization Name:LORIS EYE ASSOCIATES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:P
Authorized Official - Last Name:RAY
Authorized Official - Suffix:
Authorized Official - Credentials:O D
Authorized Official - Phone:843-756-1262
Mailing Address - Street 1:3911 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LORIS
Mailing Address - State:SC
Mailing Address - Zip Code:29569-3017
Mailing Address - Country:US
Mailing Address - Phone:843-756-1262
Mailing Address - Fax:843-756-6667
Practice Address - Street 1:3911 MAIN ST
Practice Address - Street 2:
Practice Address - City:LORIS
Practice Address - State:SC
Practice Address - Zip Code:29569-3017
Practice Address - Country:US
Practice Address - Phone:843-756-1262
Practice Address - Fax:843-756-6667
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-08
Last Update Date:2024-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC860152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCDA9737Medicaid
1316890001Medicare NSC
SCT237570281Medicare PIN
SCT23757Medicare UPIN