=====================================================
General NPI Number Information
=====================================================
NPI Number | 1447017447
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | STAAR LABS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/05/2024
-----------------------------------------------------
Last Update Date | 03/05/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 179 COUNTY ROAD 704
-----------------------------------------------------
City | ATHENS
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37303-6011
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-975-9320
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 179 COUNTY ROAD 704
-----------------------------------------------------
City | ATHENS
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37303-6011
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-975-9320
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | VICTOR POTEET
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 305-204-2147
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------