Healthcare Provider Details

I. General information

NPI: 1740280205
Provider Name (Legal Business Name): STEVE LUTTRELL SULLINS O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2005
Last Update Date: 11/14/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 GIN OAKS CT
MADISON AL
35758-1736
US

IV. Provider business mailing address

104 GIN OAKS CT
MADISON AL
35758-1736
US

V. Phone/Fax

Practice location:
  • Phone: 256-464-6670
  • Fax: 256-464-6671
Mailing address:
  • Phone: 256-464-6670
  • Fax: 256-464-6671

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberS-761-TA-167
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: