Provider Demographics
NPI:1881197648
Name:JACKSON DAVENPORT VISION SERVICES , LLC
Entity Type:Organization
Organization Name:JACKSON DAVENPORT VISION SERVICES , LLC
Other - Org Name:JACKSON DAVNPORT VISION CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:MR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:RICHARD
Authorized Official - Last Name:DAVENPORT
Authorized Official - Suffix:II
Authorized Official - Credentials:
Authorized Official - Phone:843-871-9750
Mailing Address - Street 1:218 OLD TROLLEY RD
Mailing Address - Street 2:
Mailing Address - City:SUMMERVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29485-4929
Mailing Address - Country:US
Mailing Address - Phone:843-871-9750
Mailing Address - Fax:843-873-6797
Practice Address - Street 1:101 OLD TROLLEY RD
Practice Address - Street 2:
Practice Address - City:SUMMERVILLE
Practice Address - State:SC
Practice Address - Zip Code:29485-4908
Practice Address - Country:US
Practice Address - Phone:843-871-9750
Practice Address - Fax:843-873-6797
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-17
Last Update Date:2023-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1815152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty