Healthcare Provider Details

I. General information

NPI: 1629014469
Provider Name (Legal Business Name): DECATUR OPTICAL DISPENSARY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/21/2006
Last Update Date: 01/14/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 6TH AVE SE
DECATUR AL
35601-3115
US

IV. Provider business mailing address

201 6TH AVE SE
DECATUR AL
35601-3115
US

V. Phone/Fax

Practice location:
  • Phone: 256-351-0040
  • Fax: 256-301-9449
Mailing address:
  • Phone: 256-351-0040
  • Fax: 256-301-9449

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number State

VIII. Authorized Official

Name: MR. JACK LYNN HOLBERT
Title or Position: PRESIDENT
Credential:
Phone: 256-351-0040