Provider Demographics
NPI:1134448806
Name:CAROLINA VISION ASSOCIATES, LLC
Entity type:Organization
Organization Name:CAROLINA VISION ASSOCIATES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:864-583-3125
Mailing Address - Street 1:180 N. DEAN STREET
Mailing Address - Street 2:
Mailing Address - City:SPARTANBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29302
Mailing Address - Country:US
Mailing Address - Phone:864-583-3125
Mailing Address - Fax:864-542-1367
Practice Address - Street 1:363 E. GEORGIA ST
Practice Address - Street 2:
Practice Address - City:WOODRUFF
Practice Address - State:SC
Practice Address - Zip Code:29388
Practice Address - Country:US
Practice Address - Phone:864-476-8322
Practice Address - Fax:864-476-0752
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CAROLINA VISION ASSOCIATES, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-05-20
Last Update Date:2013-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1092152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCDA9837Medicaid
SC4233070002Medicare NSC