MEDICARE: SULLINS EYE CARE CENTER, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	S-761-TA-167	AL

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	K232	OTHER	AL	MEDICARE GROUP PIN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	Q949	OTHER	AL	BCBS OF ALABAMA GROUP PIN
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1578744868
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SULLINS EYE CARE CENTER, INC.

Provider Business Mailing Address
First Line	:	104 GIN OAKS CT
Second Line	:
City	:	MADISON
State	:	AL
Zip	:	35758-1736
Country	:	US
Telephone Number	:	256-464-6670
Fax Number	:	256-464-6670

Provider Business Practice Location Address
First Line	:	104 GIN OAKS CT
Second Line	:
City	:	MADISON
State	:	AL
Zip	:	35758-1736
Country	:	US
Telephone Number	:	256-464-6670
Fax Number	:	256-464-6670

Authorized Official
Title or Position	:	BUSINESS MANAGER
Name	:	LYNNE TIDWELL
Credential	:
Telephone Number	:	256-464-6670

Provider Enumeration Date	:	11/15/2007
Last Update Date	:	11/21/2012

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