=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396561650
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EYECARE SOUTH LLC - SHOALS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/02/2024
-----------------------------------------------------
Last Update Date | 12/02/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 401 COX BLVD STE B
-----------------------------------------------------
City | SHEFFIELD
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35660-4059
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 256-314-4424
-----------------------------------------------------
Fax | 877-726-1358
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 401 COX BLVD STE B
-----------------------------------------------------
City | SHEFFIELD
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35660-4059
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 256-314-4424
-----------------------------------------------------
Fax | 877-726-1358
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CO-OWNER
-----------------------------------------------------
Name | JEREMY CAMPBELL
-----------------------------------------------------
Credential | OD
-----------------------------------------------------
Telephone | 256-314-4424
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------