Provider Demographics
NPI:1043513542
Name:PALMETTO STATE EYECARE, LLC
Entity Type:Organization
Organization Name:PALMETTO STATE EYECARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:FERINE
Authorized Official - Middle Name:N
Authorized Official - Last Name:JOHANNES
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:920-915-3422
Mailing Address - Street 1:244 LOTHROP HILL RD
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:SC
Mailing Address - Zip Code:29072-7747
Mailing Address - Country:US
Mailing Address - Phone:920-915-3422
Mailing Address - Fax:
Practice Address - Street 1:5426 FOREST DR
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29206-5401
Practice Address - Country:US
Practice Address - Phone:803-767-9964
Practice Address - Fax:803-790-2163
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-06
Last Update Date:2010-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1568152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty