Provider Demographics
NPI:1649321647
Name:CUSTOM EYES VISION CARE INC
Entity type:Organization
Organization Name:CUSTOM EYES VISION CARE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:
Authorized Official - Last Name:REYNOLDS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:843-824-2424
Mailing Address - Street 1:53 NORVIEW DR
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29407-3714
Mailing Address - Country:US
Mailing Address - Phone:843-824-2424
Mailing Address - Fax:844-394-2068
Practice Address - Street 1:7400 RIVERS AVE
Practice Address - Street 2:
Practice Address - City:NORTH CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29406-4644
Practice Address - Country:US
Practice Address - Phone:843-824-2424
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-16
Last Update Date:2020-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1229152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCDA9663Medicaid
SC8774Medicare PIN
SCU914998774Medicare UPIN