Healthcare Provider Details

I. General information

NPI: 1316012099
Provider Name (Legal Business Name): OPTOMETRIC CENTER PROFESSIONAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/21/2006
Last Update Date: 06/21/2021
Certification Date: 06/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

113 E LOCUST ST
DRESDEN TN
38225-1440
US

IV. Provider business mailing address

113 EAST LOCUST ST
DRESDEN TN
38225-0031
US

V. Phone/Fax

Practice location:
  • Phone: 731-364-2150
  • Fax: 731-364-5157
Mailing address:
  • Phone: 731-364-2150
  • Fax: 731-364-5157

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberODT241
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State

VIII. Authorized Official

Name: MR. EDWIN G ANDERSON
Title or Position: OWNER
Credential: OD
Phone: 731-364-2150