Provider Demographics
NPI:1972628055
Name:MACMILLAN OPTICAL, INC.
Entity Type:Organization
Organization Name:MACMILLAN OPTICAL, INC.
Other - Org Name:SPARTANBURG VISION WEST
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TOM
Authorized Official - Middle Name:
Authorized Official - Last Name:MACMILLAN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:864-576-0564
Mailing Address - Street 1:227 E BLACKSTOCK RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:SPARTANBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29301-2631
Mailing Address - Country:US
Mailing Address - Phone:864-576-0564
Mailing Address - Fax:864-576-0594
Practice Address - Street 1:227 E BLACKSTOCK RD
Practice Address - Street 2:SUITE 200
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29301-2631
Practice Address - Country:US
Practice Address - Phone:864-576-0564
Practice Address - Fax:864-576-0594
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MACMILLAN, OPTICAL, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-03-20
Last Update Date:2008-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC991152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCDO9916Medicaid
AA05987266Medicare UPIN