Provider Demographics
NPI:1447383831
Name:CLEMSON EYE, PA
Entity type:Organization
Organization Name:CLEMSON EYE, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:S
Authorized Official - Last Name:BECKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-243-2259
Mailing Address - Street 1:PO BOX 896189
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28289-6189
Mailing Address - Country:US
Mailing Address - Phone:864-654-6706
Mailing Address - Fax:
Practice Address - Street 1:360 PELHAM RD
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29615-3111
Practice Address - Country:US
Practice Address - Phone:864-654-6706
Practice Address - Fax:864-292-2020
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-14
Last Update Date:2025-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC17209152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCPA1747Medicaid
SCDA9729Medicaid
SC1252210001OtherDMERC MAC SUPPLIER ID
SC9429296OtherMULTIPLAN GROUP
SCCH3387OtherMEDICARE RAILROAD GROUP