Provider Demographics
NPI:1174806053
Name:DISTINCTIVE EYEWEAR VISION CENTER
Entity type:Organization
Organization Name:DISTINCTIVE EYEWEAR VISION CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LAURI
Authorized Official - Middle Name:BALDWIN
Authorized Official - Last Name:GRAHAM
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:843-213-1201
Mailing Address - Street 1:1206 MOSER DR
Mailing Address - Street 2:THE MARKET COMMON
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29577-1575
Mailing Address - Country:US
Mailing Address - Phone:843-213-1201
Mailing Address - Fax:
Practice Address - Street 1:1206 MOSER DR
Practice Address - Street 2:THE MARKET COMMON
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29577-1575
Practice Address - Country:US
Practice Address - Phone:843-213-1201
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-27
Last Update Date:2011-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1396152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty