Provider Demographics
NPI:1164472098
Name:WESTSIDE EYE CENTER LLC
Entity Type:Organization
Organization Name:WESTSIDE EYE CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LAWRENCE
Authorized Official - Middle Name:E
Authorized Official - Last Name:ROEL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:864-574-7767
Mailing Address - Street 1:735 EAST MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SPARTANBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29302-1281
Mailing Address - Country:US
Mailing Address - Phone:864-542-1308
Mailing Address - Fax:
Practice Address - Street 1:1413 JOHN B WHITE SR BLVD
Practice Address - Street 2:SUITE D
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29306-3995
Practice Address - Country:US
Practice Address - Phone:864-574-7767
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-11
Last Update Date:2007-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC14463261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCASC056Medicaid