Provider Demographics
NPI:1801983705
Name:DR. E. M. POOLE JR. LLC
Entity type:Organization
Organization Name:DR. E. M. POOLE JR. LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:EDGAR
Authorized Official - Middle Name:MORGAN
Authorized Official - Last Name:POOLE
Authorized Official - Suffix:JR
Authorized Official - Credentials:OD
Authorized Official - Phone:864-585-3281
Mailing Address - Street 1:705 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SPARTANBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29302-1281
Mailing Address - Country:US
Mailing Address - Phone:864-585-3281
Mailing Address - Fax:864-585-2255
Practice Address - Street 1:705 E MAIN ST
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29302-1281
Practice Address - Country:US
Practice Address - Phone:864-585-3281
Practice Address - Fax:864-585-2255
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-10
Last Update Date:2011-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC539152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCD05395Medicaid
SCT245820281Medicare Oscar/Certification
SCT24582Medicare UPIN
SC5884910001Medicare NSC
SCD05395Medicaid