1659449015 NPI number — EYECARE FOR LIFE, PC

Table of content: (NPI 1659449015)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659449015 NPI number — EYECARE FOR LIFE, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EYECARE FOR LIFE, PC
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:
6
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:
1659449015
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
15255 HWY 43
Provider Second Line Business Mailing Address:
2ND FL
Provider Business Mailing Address City Name:
RUSSELLVILLE
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
35653-1925
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
256-332-5440
Provider Business Mailing Address Fax Number:
256-332-5403

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
15255 HIGHWAY 43
Provider Second Line Business Practice Location Address:
2ND FL
Provider Business Practice Location Address City Name:
RUSSELLVILLE
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
35653-1924
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
256-332-5440
Provider Business Practice Location Address Fax Number:
256-332-5403
Provider Enumeration Date:
12/01/2006

Additional Information

Authorized Official

Authorized Official Last Name:
GREENBERG
Authorized Official First Name:
STUART
Authorized Official Middle Name:
M
Authorized Official Title or Position:
PRESIDENT/OWNER/PHYSICIAN
Authorized Official Telephone Number:
256-332-5440

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , 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: 07608091 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 529932110 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 894967095A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1505923 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".




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