Provider Demographics
NPI:1396276630
Name:SUMMERVILLE PRIMARY EYECARE LLC
Entity type:Organization
Organization Name:SUMMERVILLE PRIMARY EYECARE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:LLC MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:KELLI
Authorized Official - Middle Name:
Authorized Official - Last Name:MCCARTNEY
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:304-982-4964
Mailing Address - Street 1:209 BELLFLOWER DR
Mailing Address - Street 2:
Mailing Address - City:SUMMERVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29483-6657
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:450 AZALEA SQUARE BLVD
Practice Address - Street 2:
Practice Address - City:SUMMERVILLE
Practice Address - State:SC
Practice Address - Zip Code:29483-7321
Practice Address - Country:US
Practice Address - Phone:843-486-3572
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-27
Last Update Date:2017-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1850152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty