Healthcare Provider Details

I. General information

NPI: 1326105859
Provider Name (Legal Business Name): TANNER OPTICAL, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/03/2007
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

305 SHIRLEY AVE
DOUGLAS GA
31533-2333
US

IV. Provider business mailing address

305 SHIRLEY AVE
DOUGLAS GA
31533-2333
US

V. Phone/Fax

Practice location:
  • Phone: 912-383-7212
  • Fax: 912-384-4924
Mailing address:
  • Phone: 912-383-7212
  • Fax: 912-384-4924

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPT001767
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number State

VIII. Authorized Official

Name: DR. KEVIN ADAM MURPHY
Title or Position: OPTOMETRIST
Credential: OD
Phone: 912-383-7212