Provider Demographics
NPI:1134309263
Name:PROFESSIONAL OPTICAL
Entity Type:Organization
Organization Name:PROFESSIONAL OPTICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:KULZE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:843-556-2357
Mailing Address - Street 1:2270 ASHLEY CROSSING DR
Mailing Address - Street 2:STE 100
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29414-5749
Mailing Address - Country:US
Mailing Address - Phone:843-571-3967
Mailing Address - Fax:
Practice Address - Street 1:2270 ASHLEY CROSSING DR
Practice Address - Street 2:STE 100
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29414-5749
Practice Address - Country:US
Practice Address - Phone:843-571-3967
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-06
Last Update Date:2008-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC156FX1800X, 207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Multi-Specialty
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC1081960001Medicare NSC