Provider Demographics
NPI:1801945019
Name:SUMTER OPTICAL, LLC
Entity type:Organization
Organization Name:SUMTER OPTICAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING
Authorized Official - Prefix:MRS
Authorized Official - First Name:KRISTIN
Authorized Official - Middle Name:ELIZABETH
Authorized Official - Last Name:GAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-905-8047
Mailing Address - Street 1:365 WEST WESMARK BLVD
Mailing Address - Street 2:
Mailing Address - City:SUMTER
Mailing Address - State:SC
Mailing Address - Zip Code:29150
Mailing Address - Country:US
Mailing Address - Phone:803-905-8047
Mailing Address - Fax:803-905-8090
Practice Address - Street 1:365 WEST WESMARK BLVD
Practice Address - Street 2:
Practice Address - City:SUMTER
Practice Address - State:SC
Practice Address - Zip Code:29150
Practice Address - Country:US
Practice Address - Phone:803-905-8047
Practice Address - Fax:803-905-8047
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-09
Last Update Date:2014-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC043168838332H00000X
332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP3423Medicaid
SC4470120001Medicare NSC
SC4470120001Medicare UPIN