Provider Demographics
NPI:1255401352
Name:PEE DEE OPTICAL
Entity type:Organization
Organization Name:PEE DEE OPTICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT / MANAGING PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:R
Authorized Official - Last Name:STOKES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:843-669-4156
Mailing Address - Street 1:367 WEST EVANS STREET
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:SC
Mailing Address - Zip Code:29501-3429
Mailing Address - Country:US
Mailing Address - Phone:843-665-4343
Mailing Address - Fax:
Practice Address - Street 1:367 WEST EVANS STREET
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:SC
Practice Address - Zip Code:29501
Practice Address - Country:US
Practice Address - Phone:843-665-4343
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-08
Last Update Date:2019-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCSC710335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC0617670001Medicare NSC