Provider Demographics
NPI:1790862597
Name:EAST COAST OPTOMETRIC, INC
Entity Type:Organization
Organization Name:EAST COAST OPTOMETRIC, INC
Other - Org Name:H. RUBIN VISION CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:THIRD PARTY ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:TONYA
Authorized Official - Middle Name:R
Authorized Official - Last Name:NANCE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-779-9313
Mailing Address - Street 1:7539 GARNERS FERRY RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29209
Mailing Address - Country:US
Mailing Address - Phone:803-779-9313
Mailing Address - Fax:803-779-9551
Practice Address - Street 1:901 BUSH RIVER RD
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29210
Practice Address - Country:US
Practice Address - Phone:803-798-2290
Practice Address - Fax:803-731-5778
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2010-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1028152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCDA9957Medicaid
SC5420130005Medicare NSC
SC8213Medicare PIN
SCDA9957Medicaid
SC5420130003Medicare NSC