Provider Demographics
NPI:1568642783
Name:ST. PAUL'S FAMILY EYE CARE
Entity Type:Organization
Organization Name:ST. PAUL'S FAMILY EYE CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, OPTICIAN
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:BOINEAU
Authorized Official - Suffix:
Authorized Official - Credentials:OPTICIAN
Authorized Official - Phone:843-889-9366
Mailing Address - Street 1:PO BOX 38
Mailing Address - Street 2:
Mailing Address - City:ADAMS RUN
Mailing Address - State:SC
Mailing Address - Zip Code:29426-0038
Mailing Address - Country:US
Mailing Address - Phone:843-889-9366
Mailing Address - Fax:843-889-9133
Practice Address - Street 1:7610 HIGHWAY 164
Practice Address - Street 2:
Practice Address - City:HOLLYWOOD
Practice Address - State:SC
Practice Address - Zip Code:29449-5934
Practice Address - Country:US
Practice Address - Phone:843-889-9366
Practice Address - Fax:843-889-9133
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-05
Last Update Date:2007-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC730156F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156F00000XEye and Vision Services ProvidersTechnician/TechnologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCDV7305Medicaid