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General NPI Number Information
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NPI Number | 1578744868
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Entity Type | Organization
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Legal Business Name | SULLINS EYE CARE CENTER, INC.
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Dates
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Enumeration Date | 11/15/2007
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Last Update Date | 11/21/2012
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Provider Practice Location Address
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Address Line | 104 GIN OAKS CT
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City | MADISON
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State | AL
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Zip | 35758-1736
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Country | US
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Telephone | 256-464-6670
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Fax | 256-464-6670
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Provider Business Mailing Address
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Address Line | 104 GIN OAKS CT
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City | MADISON
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State | AL
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Zip | 35758-1736
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Country | US
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Telephone | 256-464-6670
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Fax | 256-464-6670
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Authorized Official
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Title or Position | BUSINESS MANAGER
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Name | LYNNE TIDWELL
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Credential |
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Telephone | 256-464-6670
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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 | S-761-TA-167
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License Number State | AL
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