Provider Demographics
NPI:1649331547
Name:BOINEAU, SUSAN (OPTICIAN)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:BOINEAU
Suffix:
Gender:F
Credentials:OPTICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 38
Mailing Address - Street 2:
Mailing Address - City:ADAMS RUN
Mailing Address - State:SC
Mailing Address - Zip Code:29426-0038
Mailing Address - Country:US
Mailing Address - Phone:843-889-9366
Mailing Address - Fax:843-889-9940
Practice Address - Street 1:7610 HIGHWAY 164
Practice Address - Street 2:
Practice Address - City:HOLLYWOOD
Practice Address - State:SC
Practice Address - Zip Code:29449-5934
Practice Address - Country:US
Practice Address - Phone:843-889-9366
Practice Address - Fax:843-889-9940
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2007-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC730156F00000X
247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156F00000XEye and Vision Services ProvidersTechnician/Technologist
No247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCVA9961Medicaid