Provider Demographics
NPI:1487880514
Name:PROFESSIONAL EYECARE CORPORATION
Entity type:Organization
Organization Name:PROFESSIONAL EYECARE CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MONIE
Authorized Official - Middle Name:
Authorized Official - Last Name:CLIFTON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:803-746-7711
Mailing Address - Street 1:439 CHANNEL RD
Mailing Address - Street 2:STE 103
Mailing Address - City:LAKE WYLIE
Mailing Address - State:SC
Mailing Address - Zip Code:29710-6102
Mailing Address - Country:US
Mailing Address - Phone:803-746-7711
Mailing Address - Fax:803-746-7189
Practice Address - Street 1:439 CHANNEL RD
Practice Address - Street 2:STE 103
Practice Address - City:LAKE WYLIE
Practice Address - State:SC
Practice Address - Zip Code:29710-6102
Practice Address - Country:US
Practice Address - Phone:803-746-7711
Practice Address - Fax:803-746-7189
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PROFESSIONAL EYECARE CORPORATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-06-03
Last Update Date:2013-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1448152W00000X
SC1447152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
9419Medicare PIN