Healthcare Provider Details

I. General information

NPI: 1699760900
Provider Name (Legal Business Name): EYE CARE CENTER ASSOCIATES PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/13/2005
Last Update Date: 10/16/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 N JACKSON ST
TULLAHOMA TN
37388-2336
US

IV. Provider business mailing address

1100 N JACKSON ST
TULLAHOMA TN
37388-2336
US

V. Phone/Fax

Practice location:
  • Phone: 931-393-2020
  • Fax: 931-455-6501
Mailing address:
  • Phone: 931-393-2020
  • Fax: 931-455-6501

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number
License Number State

VIII. Authorized Official

Name: DARYL DEMONBREUN
Title or Position: ADMINISTRATOR
Credential:
Phone: 931-393-2020