Provider Demographics
NPI:1609267756
Name:SOUTHERN EYE OPTICAL LLC
Entity Type:Organization
Organization Name:SOUTHERN EYE OPTICAL LLC
Other - Org Name:SOUTHERN EYE ASSOCIATES, PA
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:B
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:864-220-0737
Mailing Address - Street 1:113 DOCTORS DR
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29605-5608
Mailing Address - Country:US
Mailing Address - Phone:864-269-3333
Mailing Address - Fax:864-295-1288
Practice Address - Street 1:113 DOCTORS DR
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29605-5608
Practice Address - Country:US
Practice Address - Phone:864-269-3333
Practice Address - Fax:864-295-1288
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SOUTHERN EYE ASSOCIATES SOLE MBR
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-02-11
Last Update Date:2015-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC7368890001OtherMEDICARE DMERC
SC7368890002OtherMEDICARE DMERC