Provider Demographics
NPI:1568795110
Name:COOSAW EYE CENTER
Entity Type:Organization
Organization Name:COOSAW EYE CENTER
Other - Org Name:FESTIVAL EYE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:E
Authorized Official - Last Name:TALKIE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:843-767-2328
Mailing Address - Street 1:8484 DORCHESTER RD # B3
Mailing Address - Street 2:
Mailing Address - City:NORTH CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29420-7319
Mailing Address - Country:US
Mailing Address - Phone:843-767-2328
Mailing Address - Fax:
Practice Address - Street 1:8484 DORCHESTER RD # B3
Practice Address - Street 2:
Practice Address - City:NORTH CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29420-7319
Practice Address - Country:US
Practice Address - Phone:843-767-2328
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-15
Last Update Date:2009-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC878152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC1558353409Medicaid