Provider Demographics
NPI:1104001536
Name:BOWEN, LELAND HAROLD (OD)
Entity Type:Individual
Prefix:
First Name:LELAND
Middle Name:HAROLD
Last Name:BOWEN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 TRINITY ST
Mailing Address - Street 2:
Mailing Address - City:ABBEVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29620-2130
Mailing Address - Country:US
Mailing Address - Phone:864-366-2020
Mailing Address - Fax:864-366-5108
Practice Address - Street 1:100 TRINITY ST
Practice Address - Street 2:
Practice Address - City:ABBEVILLE
Practice Address - State:SC
Practice Address - Zip Code:29620-2130
Practice Address - Country:US
Practice Address - Phone:864-366-2020
Practice Address - Fax:864-366-5108
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-03
Last Update Date:2008-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1084152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCDA9853Medicaid
SCD10842Medicaid
SCD10842Medicaid
SCU69178Medicare UPIN
SCDA9853Medicaid