1689768038 NPI number — EYE CARE ASSOCIATES OF THE SOUTHEAST, P.C.

Table of content: (NPI 1689768038)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689768038 NPI number — EYE CARE ASSOCIATES OF THE SOUTHEAST, P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EYE CARE ASSOCIATES OF THE SOUTHEAST, P.C.
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:
EYE CARE ASSOCIATES
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:
1689768038
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/05/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1846
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DOTHAN
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
36302-1846
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
334-794-1175
Provider Business Mailing Address Fax Number:
334-793-0619

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
111 W MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DOTHAN
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
36301
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
334-794-1175
Provider Business Practice Location Address Fax Number:
334-793-0619
Provider Enumeration Date:
10/02/2006

Additional Information

Authorized Official

Authorized Official Last Name:
FEAGIN
Authorized Official First Name:
WILLIAM
Authorized Official Middle Name:
HEATH
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
334-794-1175

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  S-429-TA-034 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 000059835 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 410022118 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 59835 . This is a "BCBS OF ALABAMA" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".




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