1881620169 NPI number — EYE CARE GROUP, PLLC

Table of content: (NPI 1881620169)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1881620169 NPI number — EYE CARE GROUP, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EYE CARE GROUP, PLLC
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:
1881620169
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/11/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 509
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HUMBOLDT
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
38343-0509
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
731-784-1186
Provider Business Mailing Address Fax Number:
731-784-8228

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2439 N CENTRAL AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HUMBOLDT
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
38343-1753
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
731-784-1186
Provider Business Practice Location Address Fax Number:
731-784-8228
Provider Enumeration Date:
06/25/2006

Additional Information

Authorized Official

Authorized Official Last Name:
LEWIS
Authorized Official First Name:
LINDY
Authorized Official Middle Name:
H
Authorized Official Title or Position:
CHIEF MANAGER
Authorized Official Telephone Number:
731-784-1186

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 332H00000X , 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: 5466560002 . This is a "MEDICARE DMEPOS" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 5466560001 . This is a "MEDICARE DMEPOS" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 4105755 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 5466560004 . This is a "MEDICARE DMEPOS" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 3729980 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 5466560003 . This is a "MEDICARE DMEPOS" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".




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