Provider Demographics
NPI:1124595319
Name:MAGNOLIA EYE ASSOCIATES INC
Entity Type:Organization
Organization Name:MAGNOLIA EYE ASSOCIATES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LAWRENCE
Authorized Official - Middle Name:R
Authorized Official - Last Name:CUSTER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:843-424-2553
Mailing Address - Street 1:9547 EDGERTON DR APT 901
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29572-5422
Mailing Address - Country:US
Mailing Address - Phone:843-424-2553
Mailing Address - Fax:
Practice Address - Street 1:2701 DAVID MCLEOD BLVD
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:SC
Practice Address - Zip Code:29501
Practice Address - Country:US
Practice Address - Phone:843-664-2000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-26
Last Update Date:2018-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty