Healthcare Provider Details

I. General information

NPI: 1942217161
Provider Name (Legal Business Name): EDGAR EARL SWAN OPTICIAN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/01/2006
Last Update Date: 08/29/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

137 W BROADWAY
GALLATIN TN
37066-2717
US

IV. Provider business mailing address

137 W BROADWAY
GALLATIN TN
37066-2717
US

V. Phone/Fax

Practice location:
  • Phone: 615-452-2111
  • Fax: 615-452-2251
Mailing address:
  • Phone: 615-452-2111
  • Fax: 615-452-2251

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156FX1800X
TaxonomyOptician
License NumberDPO0000000657
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: