Healthcare Provider Details

I. General information

NPI: 1124258009
Provider Name (Legal Business Name): CALEB NELSON TENNANT O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/25/2009
Last Update Date: 04/06/2021
Certification Date: 04/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

511 5TH ST
MOUNDSVILLE WV
26041-1901
US

IV. Provider business mailing address

PO BOX 708
MOUNDSVILLE WV
26041-0708
US

V. Phone/Fax

Practice location:
  • Phone: 304-845-1560
  • Fax: 304-845-6381
Mailing address:
  • Phone: 304-845-1560
  • Fax: 304-845-6381

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1071
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: