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General NPI Number Information
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NPI Number | 1003508797
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Entity Type | Individual
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Provider Name | TAYLOR GRACE TACKETT DOCTOR OF OPTOMETRY
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Gender | Female
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Dates
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Enumeration Date | 05/22/2023
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Last Update Date | 06/07/2023
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Provider Practice Location Address
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Address Line | 14378 HIGHWAY 43
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City | RUSSELLVILLE
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State | AL
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Zip | 35653-2568
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Country | US
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Telephone | 256-332-1355
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Fax |
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Provider Business Mailing Address
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Address Line | 7087 HIGHWAY 524
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City | RUSSELLVILLE
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State | AL
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Zip | 35653-6552
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Country | US
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Telephone | 256-460-5793
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | S-F21
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License Number State | AL
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