Provider Demographics
NPI:1700931979
Name:CAROLINA GLAUCOMA AND VISION CENTER
Entity Type:Organization
Organization Name:CAROLINA GLAUCOMA AND VISION CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ALRIC
Authorized Official - Middle Name:CHRISTOPHER
Authorized Official - Last Name:BLAKE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:803-779-4144
Mailing Address - Street 1:1 RICHLAND MEDICAL PARK DR
Mailing Address - Street 2:SUITE 210
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29203-6834
Mailing Address - Country:US
Mailing Address - Phone:803-789-4144
Mailing Address - Fax:803-779-4146
Practice Address - Street 1:1 RICHLAND MEDICAL PARK DR
Practice Address - Street 2:SUITE 210
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-6834
Practice Address - Country:US
Practice Address - Phone:803-789-4144
Practice Address - Fax:803-779-4146
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-25
Last Update Date:2009-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC17330207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC180026568OtherRAILROAD MEDICARE
SCGP1498Medicaid
SCGP1498Medicaid
SC180026568OtherRAILROAD MEDICARE