Healthcare Provider Details

I. General information

NPI: 1164602504
Provider Name (Legal Business Name): RAINSVILLE EYE CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/13/2007
Last Update Date: 02/19/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

463 MAIN ST W.
RAINSVILLE AL
35986
US

IV. Provider business mailing address

PO BOX 2120
RAINSVILLE AL
35986-2120
US

V. Phone/Fax

Practice location:
  • Phone: 256-638-2020
  • Fax: 256-638-7832
Mailing address:
  • Phone: 256-638-2020
  • Fax: 256-638-7832

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License NumberS818TA058
License Number StateAL

VIII. Authorized Official

Name: DR. DIRK D MCGULLION
Title or Position: OPTOMETRIST
Credential: OD
Phone: 256-638-2020