Provider Demographics
NPI:1972701803
Name:VILLAGE OPTICAL LLC
Entity type:Organization
Organization Name:VILLAGE OPTICAL LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:D
Authorized Official - Last Name:ELLIOTT
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:843-577-2047
Mailing Address - Street 1:130 GARDNERS CIR
Mailing Address - Street 2:PMB 159
Mailing Address - City:JOHNS ISLAND
Mailing Address - State:SC
Mailing Address - Zip Code:29455-5474
Mailing Address - Country:US
Mailing Address - Phone:843-768-0565
Mailing Address - Fax:843-768-0566
Practice Address - Street 1:634 FRESHFIELDS DRIVE
Practice Address - Street 2:
Practice Address - City:JOHNS ISLAND
Practice Address - State:SC
Practice Address - Zip Code:29455
Practice Address - Country:US
Practice Address - Phone:843-768-0565
Practice Address - Fax:843-768-0566
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-03
Last Update Date:2009-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCSC1029152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCDA9655Medicaid
SCDA9655Medicaid