1396592382 NPI number — EXCEL EYECARE, LLC

Table of content: ROBERT M. GANTT MD (NPI 1407888043)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396592382 NPI number — EXCEL EYECARE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EXCEL EYECARE, LLC
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:
1396592382
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/02/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
236 BARRINGTON CIR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ALEXANDRIA
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
36250-7205
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
256-452-1572
Provider Business Mailing Address Fax Number:
256-546-1094

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
200 WHITEMAN AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ELKINS
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
26241-3400
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
615-728-1441
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/06/2024

Additional Information

Authorized Official

Authorized Official Last Name:
JOHNSON
Authorized Official First Name:
JAY
Authorized Official Middle Name:
MICHAEL
Authorized Official Title or Position:
OWNER/PRESIDENT
Authorized Official Telephone Number:
256-452-1572

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: 09940954 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".




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