Provider Demographics
NPI:1942226337
Name:GRAND STRAND VISION SERVICES, INC.
Entity Type:Organization
Organization Name:GRAND STRAND VISION SERVICES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:TRACY
Authorized Official - Last Name:DEAN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:843-293-1555
Mailing Address - Street 1:4886 SOCASTEE BLVD
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29588-7245
Mailing Address - Country:US
Mailing Address - Phone:843-293-1555
Mailing Address - Fax:843-293-8102
Practice Address - Street 1:4886 SOCASTEE BLVD
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29588-7245
Practice Address - Country:US
Practice Address - Phone:843-293-1555
Practice Address - Fax:843-293-8102
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-15
Last Update Date:2011-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152WV0400XEye and Vision Services ProvidersOptometristVision TherapyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCDA9697Medicaid
SC9990Medicare PIN
SCDA9697Medicaid