Healthcare Provider Details

I. General information

NPI: 1720506876
Provider Name (Legal Business Name): HERITAGE EYE CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/08/2017
Last Update Date: 04/28/2022
Certification Date: 04/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12181 COUNTY LINE RD STE 190
MADISON AL
35758-7739
US

IV. Provider business mailing address

PO BOX 1189
ATHENS AL
35612-1189
US

V. Phone/Fax

Practice location:
  • Phone: 256-233-5454
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberS-993-TA-554
License Number StateAL

VIII. Authorized Official

Name: DR. CHAD L DAVIS
Title or Position: OWNER
Credential: OD
Phone: 256-233-2393