Healthcare Provider Details

I. General information

NPI: 1043477680
Provider Name (Legal Business Name): DICKSON OPTICAL PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/21/2008
Last Update Date: 06/23/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 MATHIS DR SUITE 108
DICKSON TN
37055-2000
US

IV. Provider business mailing address

110 MATHIS DR SUITE 108
DICKSON TN
37055-2000
US

V. Phone/Fax

Practice location:
  • Phone: 615-441-9996
  • Fax: 615-441-3135
Mailing address:
  • Phone: 615-441-9996
  • Fax: 615-441-3135

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: MRS. ROSIE G BRADFORD
Title or Position: ADMINISTRATOR
Credential:
Phone: 615-446-8089