Provider Demographics
NPI:1699928309
Name:OUTER VISION CORP 2
Entity type:Organization
Organization Name:OUTER VISION CORP 2
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER/OPTICIAN
Authorized Official - Prefix:
Authorized Official - First Name:DONNIE
Authorized Official - Middle Name:
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-763-2020
Mailing Address - Street 1:1890 SAM RITTENBERG BLVD
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29407-4801
Mailing Address - Country:US
Mailing Address - Phone:843-763-2020
Mailing Address - Fax:843-763-2021
Practice Address - Street 1:1890 SAM RITTENBERG BLVD
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29407-4801
Practice Address - Country:US
Practice Address - Phone:843-763-2020
Practice Address - Fax:843-763-2021
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-25
Last Update Date:2008-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCSC0551156FX1800X
SC6952305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
No305R00000XManaged Care OrganizationsPreferred Provider OrganizationGroup - Single Specialty