1164602504 NPI number — RAINSVILLE EYE CLINIC

Table of content: (NPI 1164602504)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164602504 NPI number — RAINSVILLE EYE CLINIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RAINSVILLE EYE CLINIC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1164602504
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/19/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2120
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RAINSVILLE
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
35986-2120
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
256-638-2020
Provider Business Mailing Address Fax Number:
256-638-7832

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
463 MAIN ST W.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RAINSVILLE
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
35986
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
256-638-2020
Provider Business Practice Location Address Fax Number:
256-638-7832
Provider Enumeration Date:
11/13/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
MCGULLION
Authorized Official First Name:
DIRK
Authorized Official Middle Name:
D
Authorized Official Title or Position:
OPTOMETRIST
Authorized Official Telephone Number:
256-638-2020

Provider Taxonomy Codes

  • Taxonomy code: 332H00000X , with the licence number:  S818TA058 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1126930001 . This is a "MEDICARE DME" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 58647 . This is a "BCBS" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 529503630 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".