1518155381 NPI number — DECATUR OPTICAL DISPENSARY

Table of content: (NPI 1518155381)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1518155381 NPI number — DECATUR OPTICAL DISPENSARY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DECATUR OPTICAL DISPENSARY
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:
1518155381
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/03/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
201 6TH AVE SE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DECATUR
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
35601-3115
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
256-351-0040
Provider Business Mailing Address Fax Number:
256-301-0449

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
201 6TH AVE SE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DECATUR
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
35601-3115
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
256-351-0040
Provider Business Practice Location Address Fax Number:
256-301-0449
Provider Enumeration Date:
10/05/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
HOLBERT
Authorized Official First Name:
JACK
Authorized Official Middle Name:
L
Authorized Official Title or Position:
PRES. OF COMPANY/OPTICIAN
Authorized Official Telephone Number:
256-351-0040

Provider Taxonomy Codes

  • Taxonomy code: 332H00000X , with the licence number:  332H00000X , 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: 1629014469 . This is a "NPI" identifier . This identifiers is of the category "OTHER".