Healthcare Provider Details

I. General information

NPI: 1114164993
Provider Name (Legal Business Name): CROCKETT EYE CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/15/2009
Last Update Date: 01/15/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1008 VILLAGE TRL
CALERA AL
35040-5295
US

IV. Provider business mailing address

PO BOX 7756
ROCKY MOUNT NC
27804-0756
US

V. Phone/Fax

Practice location:
  • Phone: 334-365-2020
  • Fax:
Mailing address:
  • Phone: 252-985-1371
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberS-B79-TA-791
License Number StateAL

VIII. Authorized Official

Name: JAMES E CROCKETT
Title or Position: OWNER
Credential: OD
Phone: 334-365-2020