Healthcare Provider Details

I. General information

NPI: 1497809248
Provider Name (Legal Business Name): ADVANCED EYE CARE,P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/22/2007
Last Update Date: 08/11/2021
Certification Date: 08/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

980 HIGHWAY 28 STE 104
JASPER TN
37347-3696
US

IV. Provider business mailing address

980 HIGHWAY 28 STE 104
JASPER TN
37347-3696
US

V. Phone/Fax

Practice location:
  • Phone: 423-403-4202
  • Fax: 423-403-4207
Mailing address:
  • Phone: 423-403-4202
  • Fax: 423-403-4207

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number035850
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207WX0108X
TaxonomyUveitis and Ocular Inflammatory Disease (Ophthalmology) Physician
License Number
License Number State

VIII. Authorized Official

Name: LAWRENCE RAYMOND DEBARGE
Title or Position: PRESIDENT
Credential: MD
Phone: 423-403-4202