=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558710426
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MODERN EYE GALLERY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/10/2016
-----------------------------------------------------
Last Update Date | 06/10/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12904 LEBANON RD
-----------------------------------------------------
City | MOUNT JULIET
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37122-2865
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 615-450-0050
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12904 LEBANON RD
-----------------------------------------------------
City | MOUNT JULIET
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37122-2865
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SOLE MBR
-----------------------------------------------------
Name | JOHN KIRBY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 615-450-0050
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | OD 2759
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------