1497084255 NPI number — BRANCE E. HAGOOD

Table of content: (NPI 1497084255)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497084255 NPI number — BRANCE E. HAGOOD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BRANCE E. HAGOOD
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:
HAGOOD EYE CARE
Provider Other Organization Name Type Code:
3
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:
1497084255
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/16/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
215 W BROADWAY ST
Provider Second Line Business Mailing Address:
SUITE A
Provider Business Mailing Address City Name:
ROGERSVILLE
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37857-3280
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
423-272-2345
Provider Business Mailing Address Fax Number:
423-272-3324

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
215 W BROADWAY ST
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
ROGERSVILLE
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37857-3280
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-272-2345
Provider Business Practice Location Address Fax Number:
423-272-3324
Provider Enumeration Date:
12/08/2009

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
HAGOOD
Authorized Official First Name:
BRANCE
Authorized Official Middle Name:
EDWIN
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
423-272-2345

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  OD0000001413 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 332B00000X , with the licence number: OD001413 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 3598321 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".