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General NPI Number Information
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NPI Number | 1245490630
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Entity Type | Organization
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Legal Business Name | DALE HASTY
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Dates
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Enumeration Date | 06/10/2008
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Last Update Date | 06/10/2008
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Provider Practice Location Address
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Address Line | 605 N MAIN ST
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City | SHELBYVILLE
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State | TN
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Zip | 37160-3210
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Country | US
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Telephone | 931-684-2020
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Fax | 931-684-7000
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Provider Business Mailing Address
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Address Line | 605 N MAIN ST
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City | SHELBYVILLE
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State | TN
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Zip | 37160-3210
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Country | US
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Telephone | 931-684-2020
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Fax | 931-684-7000
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Authorized Official
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Title or Position | OWNER
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Name | KENNETH DALE HASTY
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Credential | O. D.
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Telephone | 934-684-2020
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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 | ODT001018
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License Number State | TN
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