Provider Demographics
NPI:1396942876
Name:INGRAM COMPREHENSIVE EYE CARE PA
Entity type:Organization
Organization Name:INGRAM COMPREHENSIVE EYE CARE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER AND CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:D
Authorized Official - Last Name:INGRAM
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:803-782-7080
Mailing Address - Street 1:4406A FOREST DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29206-3129
Mailing Address - Country:US
Mailing Address - Phone:803-782-7080
Mailing Address - Fax:803-744-0964
Practice Address - Street 1:4406A FOREST DR
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29206-3129
Practice Address - Country:US
Practice Address - Phone:803-782-7080
Practice Address - Fax:803-744-0964
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1320152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCD13206Medicaid
SCV00500Medicare UPIN
SCD13206Medicaid