Provider Demographics
NPI:1073569547
Name:GOSNELL OPTICIANS INC
Entity Type:Organization
Organization Name:GOSNELL OPTICIANS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER OPTICIAN
Authorized Official - Prefix:MR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:BRUCE
Authorized Official - Last Name:GOSNELL
Authorized Official - Suffix:
Authorized Official - Credentials:LICENSED OPTICIAN
Authorized Official - Phone:864-233-4148
Mailing Address - Street 1:1946 AUGUSTA STREET
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29605
Mailing Address - Country:US
Mailing Address - Phone:864-233-4148
Mailing Address - Fax:864-233-3620
Practice Address - Street 1:1946 AUGUSTA STREET
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29605
Practice Address - Country:US
Practice Address - Phone:864-233-4148
Practice Address - Fax:864-233-3620
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCVA9997Medicaid
SC0241560001Medicare ID - Type Unspecified