1053373043 NPI number — MR. GEORGE R CARLTON JR. DISPENSING OPTICIAN

Table of content: MR. GEORGE R CARLTON JR. DISPENSING OPTICIAN (NPI 1053373043)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053373043 NPI number — MR. GEORGE R CARLTON JR. DISPENSING OPTICIAN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CARLTON
Provider First Name:
GEORGE
Provider Middle Name:
R
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
JR.
Provider Credential Text:
DISPENSING OPTICIAN
Provider Gender Code:
M

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:
1053373043
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/04/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
20 SOUTH DOUGLAS AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SYLACAUGA
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
35150-2951
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
256-249-9339
Provider Business Mailing Address Fax Number:
256-249-9339

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
20 SOUTH DOUGLAS AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SYLACAUGA
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
35150-2951
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
256-249-9339
Provider Business Practice Location Address Fax Number:
256-249-9339
Provider Enumeration Date:
04/05/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 156FX1800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 51004040 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".




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