Provider Demographics
NPI:1992912935
Name:KAYEKJIAN, AMY LOUISE (OD)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:LOUISE
Last Name:KAYEKJIAN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 496
Mailing Address - Street 2:
Mailing Address - City:BALLENTINE
Mailing Address - State:SC
Mailing Address - Zip Code:29002-0496
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:223 COLUMBIA AVE STE B
Practice Address - Street 2:
Practice Address - City:CHAPIN
Practice Address - State:SC
Practice Address - Zip Code:29036-8322
Practice Address - Country:US
Practice Address - Phone:803-930-0036
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-17
Last Update Date:2024-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT11505TPA152W00000X
SC2336152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0115050Medicaid
CASD0115050Medicaid
CAU84184Medicare UPIN
CA452562723OtherGROUP FEIN/TIN