Provider Demographics
NPI:1679203426
Name:WILLIAMS, KIMBERLY (LDO)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:LDO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2751 BEAVER RUN BLVD
Mailing Address - Street 2:
Mailing Address - City:SURFSIDE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29575-5385
Mailing Address - Country:US
Mailing Address - Phone:843-215-3694
Mailing Address - Fax:843-215-3738
Practice Address - Street 1:2751 BEAVER RUN BLVD
Practice Address - Street 2:
Practice Address - City:SURFSIDE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29575-5385
Practice Address - Country:US
Practice Address - Phone:843-215-3694
Practice Address - Fax:843-215-3738
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-14
Last Update Date:2022-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1000156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician