Provider Demographics
NPI:1386920031
Name:BROWN, THEODORE AVERY (LDO)
Entity type:Individual
Prefix:
First Name:THEODORE
Middle Name:AVERY
Last Name:BROWN
Suffix:
Gender:M
Credentials:LDO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 3851
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:SC
Mailing Address - Zip Code:29502
Mailing Address - Country:US
Mailing Address - Phone:843-669-0888
Mailing Address - Fax:843-669-4197
Practice Address - Street 1:189A WARLEY ST
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:SC
Practice Address - Zip Code:29501-4442
Practice Address - Country:US
Practice Address - Phone:843-669-0888
Practice Address - Fax:843-669-4197
Is Sole Proprietor?:No
Enumeration Date:2011-10-26
Last Update Date:2011-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC145156FC0800X
SC514156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
No156FC0800XEye and Vision Services ProvidersTechnician/TechnologistContact Lens