Provider Demographics
NPI:1114178787
Name:CHERRY GROVE EYE CARE
Entity Type:Organization
Organization Name:CHERRY GROVE EYE CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JOANN
Authorized Official - Middle Name:
Authorized Official - Last Name:JEFFERS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:843-249-8440
Mailing Address - Street 1:706 SEA MOUNTAIN HWY
Mailing Address - Street 2:
Mailing Address - City:NORTH MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29582-2347
Mailing Address - Country:US
Mailing Address - Phone:843-249-8440
Mailing Address - Fax:843-280-5388
Practice Address - Street 1:706 SEA MOUNTAIN HWY
Practice Address - Street 2:
Practice Address - City:NORTH MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29582-2347
Practice Address - Country:US
Practice Address - Phone:843-249-8440
Practice Address - Fax:843-280-5388
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-01
Last Update Date:2008-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC848152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC0915370001Medicare NSC