1194920967 NPI number — DRS. TIDWELL, FAULKS, AND ALLEN - OPTOMETRY, PLLC

Table of content: (NPI 1194920967)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194920967 NPI number — DRS. TIDWELL, FAULKS, AND ALLEN - OPTOMETRY, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DRS. TIDWELL, FAULKS, AND ALLEN - OPTOMETRY, PLLC
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:
6
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:
1194920967
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/16/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
610 HENSLEE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DICKSON
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37055-1211
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
615-446-2020
Provider Business Mailing Address Fax Number:
615-441-2020

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
610 HENSLEE DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DICKSON
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37055-1211
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
615-446-2020
Provider Business Practice Location Address Fax Number:
615-441-2020
Provider Enumeration Date:
06/20/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MILLER
Authorized Official First Name:
JAMIE
Authorized Official Middle Name:
LEIGH
Authorized Official Title or Position:
CERTIFIED INSURANCE TECH AND DATA E
Authorized Official Telephone Number:
615-446-2020

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 3119266 . This is a "DR DAVID FAULKS BCBST" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 3595699 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3942446 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3595690 . This is a "MEDICARE JERRY TIDWELL" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 3113993 . This is a "DR JERRY TIDWELL BCBST" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: Q007418 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 6022728 . This is a "DR ALLEN BCBST" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 3113988 . This is a "TIDWELL AND FAULKS BCBST" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".




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