Provider Demographics
NPI:1235218496
Name:BRANCH & STAFFORD OPTOMETRIC ASSOCIATES, PA
Entity Type:Organization
Organization Name:BRANCH & STAFFORD OPTOMETRIC ASSOCIATES, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:BRANCH
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:803-781-2212
Mailing Address - Street 1:PO BOX 227
Mailing Address - Street 2:
Mailing Address - City:IRMO
Mailing Address - State:SC
Mailing Address - Zip Code:29063-0227
Mailing Address - Country:US
Mailing Address - Phone:803-781-2212
Mailing Address - Fax:803-233-2883
Practice Address - Street 1:7455 IRMO DR
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29212-8636
Practice Address - Country:US
Practice Address - Phone:803-781-2212
Practice Address - Fax:803-233-2883
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-06
Last Update Date:2018-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC609,696,496,1336152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCD06964Medicaid
SCPC2500Medicaid
SC410031738OtherMEDICARE RAILROAD
SCD04966Medicaid
CAD06090Medicaid
SCD06964Medicaid
SC2928Medicare PIN