Provider Demographics
NPI:1487631867
Name:EYECARE SPECIALTIES OF CHARLESTON
Entity type:Organization
Organization Name:EYECARE SPECIALTIES OF CHARLESTON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:KIM
Authorized Official - Middle Name:
Authorized Official - Last Name:FAULKNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-577-2047
Mailing Address - Street 1:3531 MARY ADER AVE STE B
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29414-5896
Mailing Address - Country:US
Mailing Address - Phone:843-577-2047
Mailing Address - Fax:
Practice Address - Street 1:3531 MARY ADER AVE STE B
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29414-5896
Practice Address - Country:US
Practice Address - Phone:843-577-2047
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-28
Last Update Date:2019-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCDA9789Medicaid
SCDA9789Medicaid
SC1767Medicare PIN