Provider Demographics
NPI:1659674729
Name:SOUTHERLIN FAMILY OPTICAL LLC
Entity Type:Organization
Organization Name:SOUTHERLIN FAMILY OPTICAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:SOUTHERLIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:864-354-6688
Mailing Address - Street 1:2131 WOODRUFF RD
Mailing Address - Street 2:SUITE 2100 #282
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29607-5950
Mailing Address - Country:US
Mailing Address - Phone:864-458-8633
Mailing Address - Fax:
Practice Address - Street 1:2084 WOODRUFF RD
Practice Address - Street 2:SUITE B
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29607-5939
Practice Address - Country:US
Practice Address - Phone:864-458-8633
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-13
Last Update Date:2010-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1273152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty