Provider Demographics
NPI:1134169147
Name:FLORENCE PRIMARY EYE CARE, PC
Entity type:Organization
Organization Name:FLORENCE PRIMARY EYE CARE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:BRIAN
Authorized Official - Last Name:WALLACE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:843-679-9005
Mailing Address - Street 1:1305 MADISON AVE
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:SC
Mailing Address - Zip Code:29501-4528
Mailing Address - Country:US
Mailing Address - Phone:843-661-5063
Mailing Address - Fax:
Practice Address - Street 1:2014 S IRBY ST
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:SC
Practice Address - Zip Code:29505-3420
Practice Address - Country:US
Practice Address - Phone:843-679-9005
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCSC1088152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCDA9755Medicaid
SC7461Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER