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General NPI Number Information
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NPI Number | 1255316006
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Entity Type | Organization
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Legal Business Name | OAK MOUNTAIN EYE CARE PC
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Dates
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Enumeration Date | 12/14/2005
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Last Update Date | 02/21/2012
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Provider Practice Location Address
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Address Line | 4960 VALLEYDALE RD SUITE 201
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City | BIRMINGHAM
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State | AL
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Zip | 35242-4613
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Country | US
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Telephone | 205-980-5152
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Fax | 205-980-5154
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Provider Business Mailing Address
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Address Line | 4960 VALLEYDALE RD SUITE 201
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City | BIRMINGHAM
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State | AL
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Zip | 35242-4613
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Country | US
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Telephone | 205-980-5152
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Fax | 205-980-5154
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Authorized Official
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Title or Position | PRESIDENT OWNER
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Name | DR. MICHAEL D BLACKBURN
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Credential | OD
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Telephone | 205-980-5152
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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 | S672TA330
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License Number State | AL
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