Provider Demographics
NPI:1114908092
Name:GOOSE CREEK VISION CENTER, INC.
Entity Type:Organization
Organization Name:GOOSE CREEK VISION CENTER, INC.
Other - Org Name:DR. MELVIN B. WATSKY, OPTOMETRIST
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MELVIN
Authorized Official - Middle Name:B
Authorized Official - Last Name:WATSKY
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:843-797-1264
Mailing Address - Street 1:425 REDBANK RD
Mailing Address - Street 2:
Mailing Address - City:GOOSE CREEK
Mailing Address - State:SC
Mailing Address - Zip Code:29445-4505
Mailing Address - Country:US
Mailing Address - Phone:843-797-1264
Mailing Address - Fax:843-764-3602
Practice Address - Street 1:425 REDBANK RD
Practice Address - Street 2:
Practice Address - City:GOOSE CREEK
Practice Address - State:SC
Practice Address - Zip Code:29445-4505
Practice Address - Country:US
Practice Address - Phone:843-797-1264
Practice Address - Fax:843-764-3602
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-08
Last Update Date:2009-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCSC568152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCDA9765Medicaid
SCWA260115OtherHIGHMARK BC/BS GROUP #
SCT25150Medicare UPIN
SCDA9765Medicaid
SC6159080001Medicare NSC