Healthcare Provider Details

I. General information

NPI: 1659072080
Provider Name (Legal Business Name): CHATTANOOGA OPTICAL, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/13/2023
Last Update Date: 03/13/2023
Certification Date: 03/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1906 GUNBARREL RD
CHATTANOOGA TN
37421-3485
US

IV. Provider business mailing address

7720 LEGENDS WAY
CHATTANOOGA TN
37421-7101
US

V. Phone/Fax

Practice location:
  • Phone: 956-335-6476
  • Fax: 561-828-8367
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number State

VIII. Authorized Official

Name: DANIEL GARZA
Title or Position: MANAGED CARE MANAGER
Credential:
Phone: 619-357-6146