Provider Demographics
NPI:1811105877
Name:ANDERSON MULLINS, SUSAN (LICENSED OPTICIAN)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:ANDERSON MULLINS
Suffix:
Gender:F
Credentials:LICENSED OPTICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:145 ANDREWS BLVD
Mailing Address - Street 2:
Mailing Address - City:SUMMERVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29483-8606
Mailing Address - Country:US
Mailing Address - Phone:843-871-8195
Mailing Address - Fax:
Practice Address - Street 1:7685 NORTHWOODS BLVD
Practice Address - Street 2:SUITE 8 F
Practice Address - City:NORTH CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29406-4002
Practice Address - Country:US
Practice Address - Phone:843-797-2090
Practice Address - Fax:843-797-3822
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC421156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCVA9967Medicaid