Provider Demographics
NPI:1679918726
Name:NEIGHBORLY OPTICAL LLC
Entity Type:Organization
Organization Name:NEIGHBORLY OPTICAL LLC
Other - Org Name:NEIGHBORLY OPTICAL LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER/ OPTICIAN
Authorized Official - Prefix:MR
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:LAMAR
Authorized Official - Last Name:ENGRAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-552-2070
Mailing Address - Street 1:7013 DORCHESTER RD
Mailing Address - Street 2:SUITE D
Mailing Address - City:NORTH CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29418-3407
Mailing Address - Country:US
Mailing Address - Phone:843-552-2070
Mailing Address - Fax:843-552-2088
Practice Address - Street 1:7013 DORCHESTER RD
Practice Address - Street 2:SUITE D
Practice Address - City:NORTH CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29418-3407
Practice Address - Country:US
Practice Address - Phone:843-552-2070
Practice Address - Fax:843-552-2088
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-02
Last Update Date:2015-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCC942Medicare PIN