Provider Demographics
NPI:1477701431
Name:CAROLINA CATARACT CLINIC
Entity type:Organization
Organization Name:CAROLINA CATARACT CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DEAN
Authorized Official - Middle Name:R
Authorized Official - Last Name:JACOBS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:803-788-2276
Mailing Address - Street 1:PO BOX 23098
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29224-3098
Mailing Address - Country:US
Mailing Address - Phone:803-788-2276
Mailing Address - Fax:
Practice Address - Street 1:2240 W DEKALB ST
Practice Address - Street 2:WALMART VISION CENTER
Practice Address - City:CAMDEN
Practice Address - State:SC
Practice Address - Zip Code:29020-2069
Practice Address - Country:US
Practice Address - Phone:803-788-2276
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-03
Last Update Date:2008-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC12570174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP2752Medicaid
SCC61406Medicare UPIN
SC6587Medicare PIN