1104901578 NPI number — GREEN OPTICAL

Table of content: (NPI 1104901578)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104901578 NPI number — GREEN OPTICAL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GREEN OPTICAL
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:
1104901578
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/06/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
854 LONE OAK DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GALLATIN
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37066-3694
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
615-452-1602
Provider Business Mailing Address Fax Number:
615-452-9643

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
854 LONE OAK DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GALLATIN
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37066
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
615-452-1602
Provider Business Practice Location Address Fax Number:
615-452-9643
Provider Enumeration Date:
10/26/2006

Additional Information

Authorized Official

Authorized Official Last Name:
GREEN
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
EDWARD
Authorized Official Title or Position:
CHIEF PARTNER
Authorized Official Telephone Number:
615-452-1602

Provider Taxonomy Codes

  • Taxonomy code: 332H00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: OP1903 . This is a "EYEMED" identifier . This identifiers is of the category "OTHER".
  • Identifier: 021446 . This is a "BLOCK VISION" identifier . This identifiers is of the category "OTHER".
  • Identifier: 905714 . This is a "BLOCK VISION" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0191345 . This is a "TENNCARE SELECT" identifier . This identifiers is of the category "OTHER".
  • Identifier: 632 . This is a "STERLING VISION" identifier . This identifiers is of the category "OTHER".
  • Identifier: 3157442 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".




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