Provider Demographics
NPI:1780855197
Name:EYECARE CENTER OF GOOSE CREEK
Entity Type:Organization
Organization Name:EYECARE CENTER OF GOOSE CREEK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:
Authorized Official - Last Name:STRAMM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-572-2266
Mailing Address - Street 1:142 SAINT JAMES AVE UNIT A
Mailing Address - Street 2:
Mailing Address - City:GOOSE CREEK
Mailing Address - State:SC
Mailing Address - Zip Code:29445-2973
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:142 SAINT JAMES AVE UNIT A
Practice Address - Street 2:
Practice Address - City:GOOSE CREEK
Practice Address - State:SC
Practice Address - Zip Code:29445-2973
Practice Address - Country:US
Practice Address - Phone:843-572-2266
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-13
Last Update Date:2008-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC328332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC0687400001Medicare UPIN