Provider Demographics
NPI:1063681500
Name:HEATON, LAURA MEADE (OPTICIAN)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:MEADE
Last Name:HEATON
Suffix:
Gender:F
Credentials:OPTICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1598 SANDIFER BLVD STE J
Mailing Address - Street 2:
Mailing Address - City:SENECA
Mailing Address - State:SC
Mailing Address - Zip Code:29678-0929
Mailing Address - Country:US
Mailing Address - Phone:864-882-3255
Mailing Address - Fax:
Practice Address - Street 1:1598 SANDIFER BLVD STE J
Practice Address - Street 2:
Practice Address - City:SENECA
Practice Address - State:SC
Practice Address - Zip Code:29678-0929
Practice Address - Country:US
Practice Address - Phone:864-882-3255
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-02-28
Last Update Date:2008-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC734156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCDV7396Medicaid