Provider Demographics
NPI:1861803520
Name:EYES OVER CAROLINA PC
Entity type:Organization
Organization Name:EYES OVER CAROLINA PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWIN
Authorized Official - Middle Name:KYLE
Authorized Official - Last Name:MITCHELL
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:336-707-6542
Mailing Address - Street 1:316 WINDING WOOD CIR
Mailing Address - Street 2:
Mailing Address - City:BLYTHEWOOD
Mailing Address - State:SC
Mailing Address - Zip Code:29016-7843
Mailing Address - Country:US
Mailing Address - Phone:803-776-5363
Mailing Address - Fax:803-227-8996
Practice Address - Street 1:1150 S 4TH ST
Practice Address - Street 2:
Practice Address - City:HARTSVILLE
Practice Address - State:SC
Practice Address - Zip Code:29550-0705
Practice Address - Country:US
Practice Address - Phone:843-857-1999
Practice Address - Fax:803-227-8996
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-15
Last Update Date:2015-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1696152WC0802X, 152WP0200X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact ManagementGroup - Multi-Specialty
No152WP0200XEye and Vision Services ProvidersOptometristPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCDA9570Medicaid
SCDA9574Medicaid