Healthcare Provider Details

I. General information

NPI: 1841382074
Provider Name (Legal Business Name): ERIC MARSHAL SELANDER O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/28/2006
Last Update Date: 06/11/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1815 DECATUR PIKE
ATHENS TN
37303-4932
US

IV. Provider business mailing address

3608 OOLTEWAH RINGGOLD RD
OOLTEWAH TN
37363-8045
US

V. Phone/Fax

Practice location:
  • Phone: 423-745-5100
  • Fax: 423-745-1577
Mailing address:
  • Phone: 423-745-5100
  • Fax: 423-745-1577

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOD-T2529
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1141
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: