Provider Demographics
NPI:1639358724
Name:R. E. JIMISON
Entity Type:Organization
Organization Name:R. E. JIMISON
Other - Org Name:RAYMOND JIMISON
Other - Org Type:Other Name
Authorized Official - Title/Position:OPTICIAN
Authorized Official - Prefix:
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:HUMM
Authorized Official - Last Name:JIMISON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-524-8302
Mailing Address - Street 1:11 ROBERT SMALLS PKWY STE H
Mailing Address - Street 2:
Mailing Address - City:BEAUFORT
Mailing Address - State:SC
Mailing Address - Zip Code:29906-4216
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11 ROBERT SMALLS PKWY STE H
Practice Address - Street 2:
Practice Address - City:BEAUFORT
Practice Address - State:SC
Practice Address - Zip Code:29906-4216
Practice Address - Country:US
Practice Address - Phone:843-524-8302
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-25
Last Update Date:2011-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC634332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC140732Medicaid
SC5239080001Medicare NSC
SC140732Medicaid