Provider Demographics
NPI:1891246823
Name:SURGE EYE ASSOCIATES, LLC
Entity Type:Organization
Organization Name:SURGE EYE ASSOCIATES, LLC
Other - Org Name:SURGE EYE ASSOCIATES, LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRISTIE
Authorized Official - Middle Name:A
Authorized Official - Last Name:ALTICE-WEAVER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:843-457-2020
Mailing Address - Street 1:240 LANDS END BLVD
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29572-7054
Mailing Address - Country:US
Mailing Address - Phone:843-457-2020
Mailing Address - Fax:
Practice Address - Street 1:240 LANDS END BLVD
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29572-7054
Practice Address - Country:US
Practice Address - Phone:843-457-2020
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-14
Last Update Date:2016-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618001011152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA009237267Medicaid
VA009237267Medicaid