Provider Demographics
NPI:1629254107
Name:RUSSELL EYECARE
Entity Type:Organization
Organization Name:RUSSELL EYECARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER
Authorized Official - Prefix:DR
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:O
Authorized Official - Last Name:RUSSELL
Authorized Official - Suffix:III
Authorized Official - Credentials:OD
Authorized Official - Phone:843-662-3278
Mailing Address - Street 1:240 W EVANS ST
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:SC
Mailing Address - Zip Code:29501-3428
Mailing Address - Country:US
Mailing Address - Phone:843-662-3278
Mailing Address - Fax:843-667-6090
Practice Address - Street 1:240 W EVANS ST
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:SC
Practice Address - Zip Code:29501-3428
Practice Address - Country:US
Practice Address - Phone:843-662-3278
Practice Address - Fax:843-667-6090
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-15
Last Update Date:2011-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC601332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCD06018Medicaid
SCT23975Medicare UPIN
SCD06018Medicaid
SC0635910001Medicare NSC