Provider Demographics
NPI:1558448852
Name:PELHAM VISION CENTER, PA
Entity Type:Organization
Organization Name:PELHAM VISION CENTER, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KERRY
Authorized Official - Middle Name:R
Authorized Official - Last Name:STECK
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:864-627-0634
Mailing Address - Street 1:317 THE PKWY
Mailing Address - Street 2:
Mailing Address - City:GREER
Mailing Address - State:SC
Mailing Address - Zip Code:29650-4569
Mailing Address - Country:US
Mailing Address - Phone:864-627-0634
Mailing Address - Fax:864-627-1960
Practice Address - Street 1:317 THE PKWY
Practice Address - Street 2:
Practice Address - City:GREER
Practice Address - State:SC
Practice Address - Zip Code:29650-4569
Practice Address - Country:US
Practice Address - Phone:864-627-0634
Practice Address - Fax:864-627-1960
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2012-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC945152W00000X
SC1072152W00000X
SC1707152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCDA9947Medicaid
SC9320Medicare UPIN