Healthcare Provider Details

I. General information

NPI: 1720142771
Provider Name (Legal Business Name): SULLINS EYE CARE P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/21/2006
Last Update Date: 10/31/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 ENGLEWOOD RD
MADISONVILLE TN
37354-1218
US

IV. Provider business mailing address

PO BOX 247
MADISONVILLE TN
37354-0247
US

V. Phone/Fax

Practice location:
  • Phone: 423-442-2806
  • Fax:
Mailing address:
  • Phone: 423-442-2806
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOD0000001899
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOD0000001722
License Number StateTN
# 3
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOD0000001689
License Number StateTN

VIII. Authorized Official

Name: CHRISTA H. SULLINS
Title or Position: OPTOMETRIST
Credential: OD
Phone: 423-442-2806