Healthcare Provider Details

I. General information

NPI: 1720161425
Provider Name (Legal Business Name): LORRAINE DEANGELIS SUMMERLIN O. D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/24/2006
Last Update Date: 04/08/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5447 MAIN ST
GRANT AL
35747-8322
US

IV. Provider business mailing address

5447 MAIN ST
GRANT AL
35747-8322
US

V. Phone/Fax

Practice location:
  • Phone: 256-728-3937
  • Fax: 256-728-3938
Mailing address:
  • Phone: 256-728-3937
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberS969TA526
License Number StateAL
# 2
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPT001876
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOD0000002212
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: