Provider Demographics
NPI:1548329097
Name:ANGEL OAK EYE CENTER
Entity type:Organization
Organization Name:ANGEL OAK EYE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:W
Authorized Official - Last Name:BOHAC
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:843-559-5333
Mailing Address - Street 1:PO BOX 874
Mailing Address - Street 2:
Mailing Address - City:JOHNS ISLAND
Mailing Address - State:SC
Mailing Address - Zip Code:29457-0874
Mailing Address - Country:US
Mailing Address - Phone:843-559-5333
Mailing Address - Fax:843-559-5339
Practice Address - Street 1:2875 MAYBANK HWY
Practice Address - Street 2:
Practice Address - City:JOHNS ISLAND
Practice Address - State:SC
Practice Address - Zip Code:29455-4808
Practice Address - Country:US
Practice Address - Phone:843-559-5333
Practice Address - Fax:843-559-5339
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-08
Last Update Date:2008-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC907152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCDA9762Medicaid
SCDO9070Medicaid
SCDO9070Medicaid
SCT931727306Medicare ID - Type UnspecifiedMEDICARE
SCT93172Medicare UPIN
SCDA9762Medicaid