Provider Demographics
NPI:1043482722
Name:TEGA CAY EYE CARE, LLC
Entity Type:Organization
Organization Name:TEGA CAY EYE CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:F
Authorized Official - Last Name:JERGE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:803-802-4733
Mailing Address - Street 1:600 PINE LINKS DR
Mailing Address - Street 2:
Mailing Address - City:TEGA CAY
Mailing Address - State:SC
Mailing Address - Zip Code:29704-7205
Mailing Address - Country:US
Mailing Address - Phone:803-802-4733
Mailing Address - Fax:803-802-4735
Practice Address - Street 1:1151 STONECREST BLVD
Practice Address - Street 2:
Practice Address - City:TEGA CAY
Practice Address - State:SC
Practice Address - Zip Code:29708
Practice Address - Country:US
Practice Address - Phone:803-802-4733
Practice Address - Fax:803-802-4735
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-02
Last Update Date:2013-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1468152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCD14688Medicaid
SC11730BMedicare PIN
SCT88312Medicare UPIN