Provider Demographics
NPI:1912611971
Name:PARK CIRCLE VISION LLC
Entity Type:Organization
Organization Name:PARK CIRCLE VISION LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:JESSE
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLINGHAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-203-0200
Mailing Address - Street 1:1816 SUCCESS ST STE 101
Mailing Address - Street 2:
Mailing Address - City:NORTH CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29405-7851
Mailing Address - Country:US
Mailing Address - Phone:843-203-0200
Mailing Address - Fax:
Practice Address - Street 1:1816 SUCCESS ST STE 101
Practice Address - Street 2:
Practice Address - City:NORTH CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29405-7851
Practice Address - Country:US
Practice Address - Phone:843-203-0200
Practice Address - Fax:843-203-5324
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-01-12
Last Update Date:2023-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152WV0400XEye and Vision Services ProvidersOptometristVision TherapyGroup - Single Specialty