1629247762 NPI number — .JESSUP EYE CARE, INC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629247762 NPI number — .JESSUP EYE CARE, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
.JESSUP EYE CARE, INC
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:
1629247762
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/16/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7640 HIGHWAY 70 S
Provider Second Line Business Mailing Address:
SUITE 204
Provider Business Mailing Address City Name:
NASHVILLE
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37221-1758
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
615-662-2800
Provider Business Mailing Address Fax Number:
615-662-0411

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
181 THOMPSON LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NASHVILLE
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37211-2411
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
615-333-1717
Provider Business Practice Location Address Fax Number:
615-333-9245
Provider Enumeration Date:
02/22/2008

Additional Information

Authorized Official

Authorized Official Last Name:
JESSUP
Authorized Official First Name:
JEFFREY
Authorized Official Middle Name:
CARR
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
615-513-0385

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  ODT000859 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 4932109 . This is a "CIGNA" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 0792070001 . This is a "MEDICARE DMERC" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".




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