Provider Demographics
NPI:1851430839
Name:ROBERTSON OPTICAL LABORATORIES INC
Entity Type:Organization
Organization Name:ROBERTSON OPTICAL LABORATORIES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT-OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:GORDON
Authorized Official - Middle Name:QUATTLEBAUM
Authorized Official - Last Name:SCOTT
Authorized Official - Suffix:JR
Authorized Official - Credentials:SC OPTICIAN
Authorized Official - Phone:803-254-9381
Mailing Address - Street 1:1812 WASHINGTON STREET
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29201
Mailing Address - Country:US
Mailing Address - Phone:803-254-9381
Mailing Address - Fax:803-254-1978
Practice Address - Street 1:1812 WASHINGTON STREET
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29201
Practice Address - Country:US
Practice Address - Phone:803-254-9381
Practice Address - Fax:803-254-1978
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC352332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCDVO105Medicaid
SCVA9999Medicaid