Provider Demographics
NPI:1962775817
Name:WESTSIDE OPTICAL SHOP,LLC
Entity type:Organization
Organization Name:WESTSIDE OPTICAL SHOP,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:DR
Authorized Official - First Name:LAWRENCE
Authorized Official - Middle Name:EDMUND
Authorized Official - Last Name:ROEL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:864-542-1308
Mailing Address - Street 1:1413 JOHN B WHITE SR BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:SPARTANBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29306-3995
Mailing Address - Country:US
Mailing Address - Phone:864-587-1039
Mailing Address - Fax:864-587-1936
Practice Address - Street 1:1413 JOHN B WHITE SR BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29306-3995
Practice Address - Country:US
Practice Address - Phone:864-587-1039
Practice Address - Fax:864-587-1936
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-22
Last Update Date:2012-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC120021119332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC1164472098Medicaid