Provider Demographics
NPI:1760661235
Name:SPECIALTY EYE CARE OF THE CAROLINAS, PC
Entity Type:Organization
Organization Name:SPECIALTY EYE CARE OF THE CAROLINAS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SHAWN
Authorized Official - Middle Name:F
Authorized Official - Last Name:RILEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:910-754-5434
Mailing Address - Street 1:1115 48TH AVE N STE 121
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29577-5420
Mailing Address - Country:US
Mailing Address - Phone:843-449-6478
Mailing Address - Fax:843-497-8571
Practice Address - Street 1:15 MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:SUPPLY
Practice Address - State:NC
Practice Address - Zip Code:28462-3350
Practice Address - Country:US
Practice Address - Phone:910-754-5437
Practice Address - Fax:910-754-5443
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-31
Last Update Date:2007-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9300575207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC891137YMedicaid
NC1137YOtherBCBS
NC1137YOtherBCBS
NCF432532337591Medicare UPIN