1205598737 NPI number — WIREGRASS EYE CARE OF OZARK, PC

Table of content: DR. LAURA KATHLEEN SUTTIN M.D. (NPI 1548372485)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205598737 NPI number — WIREGRASS EYE CARE OF OZARK, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WIREGRASS EYE CARE OF OZARK, PC
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:
1205598737
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/16/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
231 E BROAD ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OZARK
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
36360-1507
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
334-443-1260
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
231 E BROAD ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OZARK
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
36360-1507
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
334-443-1260
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/12/2021

Additional Information

Authorized Official

Authorized Official Last Name:
CHILDERS
Authorized Official First Name:
GISELLE
Authorized Official Middle Name:
PACHECO
Authorized Official Title or Position:
OWNER, OPTOMETRIST
Authorized Official Telephone Number:
334-443-1260

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)





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