Provider Demographics
NPI:1225391915
Name:CHILDRENS EYE SPECIALISTS LLC
Entity Type:Organization
Organization Name:CHILDRENS EYE SPECIALISTS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:GUY WILLIAM
Authorized Official - Last Name:TEED
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:336-834-2220
Mailing Address - Street 1:9565 HIGHWAY 78
Mailing Address - Street 2:BLDG 600
Mailing Address - City:LADSON
Mailing Address - State:SC
Mailing Address - Zip Code:29456-4118
Mailing Address - Country:US
Mailing Address - Phone:843-202-0288
Mailing Address - Fax:843-202-0284
Practice Address - Street 1:9565 HIGHWAY 78
Practice Address - Street 2:BLDG 600
Practice Address - City:LADSON
Practice Address - State:SC
Practice Address - Zip Code:29456-4118
Practice Address - Country:US
Practice Address - Phone:843-202-0288
Practice Address - Fax:843-202-0284
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-19
Last Update Date:2012-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC29836207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP5959Medicaid