Healthcare Provider Details

I. General information

NPI: 1902894686
Provider Name (Legal Business Name): AMBRA T GLASS O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/07/2005
Last Update Date: 05/07/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

828 S BROAD ST
SCOTTSBORO AL
35768-2508
US

IV. Provider business mailing address

828 S BROAD ST
SCOTTSBORO AL
35768-2508
US

V. Phone/Fax

Practice location:
  • Phone: 256-259-4115
  • Fax: 256-259-3643
Mailing address:
  • Phone: 256-259-4115
  • Fax: 256-259-3643

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberS413TA171
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: