Provider Demographics
NPI:1699182436
Name:MIDLANDS EYE ASSOCIATES, LLC
Entity Type:Organization
Organization Name:MIDLANDS EYE ASSOCIATES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:LAWRENCE
Authorized Official - Middle Name:RAYMOND
Authorized Official - Last Name:CUSTER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:843-424-2553
Mailing Address - Street 1:268 SHOREWARD DR
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29579-5146
Mailing Address - Country:US
Mailing Address - Phone:843-424-2553
Mailing Address - Fax:
Practice Address - Street 1:470 TOWN CENTER PL STE 5
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29229-7957
Practice Address - Country:US
Practice Address - Phone:843-424-2553
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COASTAL GRAND EYE ASSOCIATES LTD. CO.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-07-14
Last Update Date:2014-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1237305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service