Basic Information
| Provider Information | |||||||||
| NPI: | 1720044514 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COLUMBIA EYE CLINIC PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 60371 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282600371 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8037793070 | ||||||||
| FaxNumber: | 8037717639 | ||||||||
| Practice Location | |||||||||
| Address1: | 1920 PICKENS ST | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 29201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8037793070 | ||||||||
| FaxNumber: | 8037717639 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/21/2006 | ||||||||
| LastUpdateDate: | 08/17/2020 | ||||||||
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| AuthorizedOfficialLastName: | SPOTTS | ||||||||
| AuthorizedOfficialFirstName: | LANGSTON | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 8037793070 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 08/17/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | Y | Ambulatory Health Care Facilities | Clinic/Center |
ID Information
| ID | Type | State | Issuer | Description | PA0187 | 05 | SC | MEDICAID |