=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013514207
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EYECARE PLUS TH PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/01/2020
-----------------------------------------------------
Last Update Date | 10/01/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1802 N JACKSON ST STE 870
-----------------------------------------------------
City | TULLAHOMA
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37388-8237
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 615-988-5303
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1802 N JACKSON ST STE 870
-----------------------------------------------------
City | TULLAHOMA
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37388-8237
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OPTOMETRIST, OWENER
-----------------------------------------------------
Name | KEVIN SCHMIDT
-----------------------------------------------------
Credential | OD
-----------------------------------------------------
Telephone | 615-988-5303
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------