Provider Demographics
NPI:1356668032
Name:COVINGTON OPTOMETRIC EYE CLINIC
Entity Type:Organization
Organization Name:COVINGTON OPTOMETRIC EYE CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE CONSULTANT
Authorized Official - Prefix:
Authorized Official - First Name:ABBIE
Authorized Official - Middle Name:C
Authorized Official - Last Name:PREVATT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-537-3641
Mailing Address - Street 1:703 MARKET ST
Mailing Address - Street 2:
Mailing Address - City:CHERAW
Mailing Address - State:SC
Mailing Address - Zip Code:29520-2658
Mailing Address - Country:US
Mailing Address - Phone:843-537-3641
Mailing Address - Fax:843-537-3646
Practice Address - Street 1:703 MARKET ST
Practice Address - Street 2:
Practice Address - City:CHERAW
Practice Address - State:SC
Practice Address - Zip Code:29520-2658
Practice Address - Country:US
Practice Address - Phone:843-537-3641
Practice Address - Fax:843-537-3646
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-21
Last Update Date:2014-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1588152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC9606Medicare PIN