Healthcare Provider Details

I. General information

NPI: 1902920507
Provider Name (Legal Business Name): EYE CENTERS OF TENNESSEE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/19/2007
Last Update Date: 04/26/2021
Certification Date: 04/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

768 S WILLOW AVE STE A
COOKEVILLE TN
38501-3892
US

IV. Provider business mailing address

15 IRIS LN
CROSSVILLE TN
38555-7528
US

V. Phone/Fax

Practice location:
  • Phone: 931-528-1567
  • Fax: 931-528-6094
Mailing address:
  • Phone: 931-456-2728
  • Fax: 931-456-5446

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code156FX1800X
TaxonomyOptician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License NumberOD723
License Number StateTN

VIII. Authorized Official

Name: MRS. TINA D BREEDING
Title or Position: FRONT OFFICE CREDENTIALING
Credential:
Phone: 931-456-2728