=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609066703
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LIGHTHOUSE OPTICAL OF TENNESSEE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/26/2007
-----------------------------------------------------
Last Update Date | 04/05/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 430 NEAL ST
-----------------------------------------------------
City | COOKEVILLE
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38501-0916
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 931-528-6411
-----------------------------------------------------
Fax | 931-372-0380
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 430 NEAL ST
-----------------------------------------------------
City | COOKEVILLE
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38501-0916
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 931-528-6411
-----------------------------------------------------
Fax | 931-372-0380
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OPTOMETRIST/OWNER
-----------------------------------------------------
Name | DR. STEPHEN MORGAN RICHARDSON
-----------------------------------------------------
Credential | O.D.
-----------------------------------------------------
Telephone | 931-528-6411
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | OD T-1155
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------