Provider Demographics
NPI:1548201908
Name:FORT MILL OPTICAL INC
Entity Type:Organization
Organization Name:FORT MILL OPTICAL INC
Other - Org Name:FORT MILL VISION CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OPTOMETRIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DEBORAH
Authorized Official - Middle Name:A
Authorized Official - Last Name:LONG
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:803-547-5547
Mailing Address - Street 1:PO BOX 1149
Mailing Address - Street 2:
Mailing Address - City:FORT MILL
Mailing Address - State:SC
Mailing Address - Zip Code:29716-1149
Mailing Address - Country:US
Mailing Address - Phone:803-547-5547
Mailing Address - Fax:803-547-5724
Practice Address - Street 1:1090 SPRATT ST
Practice Address - Street 2:
Practice Address - City:FORT MILL
Practice Address - State:SC
Practice Address - Zip Code:29715-8226
Practice Address - Country:US
Practice Address - Phone:803-547-5547
Practice Address - Fax:803-547-5724
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-09
Last Update Date:2008-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1387152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCDA9735Medicaid
SCDA9735Medicaid
SC7274Medicare PIN