Provider Demographics
NPI:1669509980
Name:MARLBORO EYE CARE ASSOCIATES, LLC
Entity Type:Organization
Organization Name:MARLBORO EYE CARE ASSOCIATES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROPRIETOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:843-479-2020
Mailing Address - Street 1:PO BOX 1094
Mailing Address - Street 2:
Mailing Address - City:BENNETTSVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29512-1094
Mailing Address - Country:US
Mailing Address - Phone:843-479-2020
Mailing Address - Fax:843-454-2020
Practice Address - Street 1:602 E MAIN ST
Practice Address - Street 2:
Practice Address - City:BENNETTSVILLE
Practice Address - State:SC
Practice Address - Zip Code:29512-3218
Practice Address - Country:US
Practice Address - Phone:843-479-2020
Practice Address - Fax:843-454-2020
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-27
Last Update Date:2008-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1222152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCDA9664Medicaid
SC5873840001Medicare NSC
SCDA9664Medicaid