Provider Demographics
NPI:1598009847
Name:REBECCA VISION LLC
Entity Type:Organization
Organization Name:REBECCA VISION LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:
Authorized Official - Last Name:POWELL
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:843-559-6748
Mailing Address - Street 1:1837 LEADENWAH DR
Mailing Address - Street 2:
Mailing Address - City:WADMALAW IS
Mailing Address - State:SC
Mailing Address - Zip Code:29487-6973
Mailing Address - Country:US
Mailing Address - Phone:843-559-6748
Mailing Address - Fax:843-559-6748
Practice Address - Street 1:1230 AMELIA ST
Practice Address - Street 2:
Practice Address - City:ORANGEBURG
Practice Address - State:SC
Practice Address - Zip Code:29115-5478
Practice Address - Country:US
Practice Address - Phone:803-531-0061
Practice Address - Fax:803-829-8026
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-26
Last Update Date:2012-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC643152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC246383Medicaid
SC246383Medicaid
SCT239820281Medicare PIN