Healthcare Provider Details

I. General information

NPI: 1306014378
Provider Name (Legal Business Name): EYE CENTERS OF TENNESSEE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/13/2008
Last Update Date: 04/26/2021
Certification Date: 04/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

220 N CHANCERY ST
MC MINNVILLE TN
37110-2551
US

IV. Provider business mailing address

15 IRIS LN
CROSSVILLE TN
38555-7528
US

V. Phone/Fax

Practice location:
  • Phone: 931-473-2487
  • Fax: 931-473-8782
Mailing address:
  • Phone: 931-456-2728
  • Fax: 931-456-5446

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOD3109
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberMD16334
License Number StateTN
# 3
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License NumberMD9365
License Number StateTN

VIII. Authorized Official

Name: MRS. TINA D BREEDING
Title or Position: FRONT OFFICE CREDENTIALING
Credential:
Phone: 931-456-2728