=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114179587
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SKYLINE EYE CLINIC, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/16/2008
-----------------------------------------------------
Last Update Date | 10/16/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 138 HOUSTON AVE
-----------------------------------------------------
City | SELMER
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38375-2127
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 731-645-7255
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 138 HOUSTON AVE
-----------------------------------------------------
City | SELMER
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38375-2127
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 731-645-7255
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR/CEO
-----------------------------------------------------
Name | RAYMOND J KEE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 731-424-2414
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 457
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------