Provider Demographics
NPI:1487198347
Name:IDEAL-EYES EYE CARE LLC
Entity Type:Organization
Organization Name:IDEAL-EYES EYE CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ASHLEY
Authorized Official - Middle Name:BROOKE
Authorized Official - Last Name:FAZZARY
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:607-228-7179
Mailing Address - Street 1:441 MEETING ST
Mailing Address - Street 2:APT 303
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29403-7807
Mailing Address - Country:US
Mailing Address - Phone:607-228-7179
Mailing Address - Fax:
Practice Address - Street 1:450 AZALEA SQUARE BLVD
Practice Address - Street 2:
Practice Address - City:SUMMERVILLE
Practice Address - State:SC
Practice Address - Zip Code:29483-7321
Practice Address - Country:US
Practice Address - Phone:843-821-0961
Practice Address - Fax:843-851-6938
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-12
Last Update Date:2016-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1931152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
J400069956Medicare PIN