=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972520807
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CAROL P. LAGRANGE, O.D., P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/16/2006
-----------------------------------------------------
Last Update Date | 08/20/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2043 GREYSTONE PARK
-----------------------------------------------------
City | JACKSON
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38305-3575
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 731-668-3424
-----------------------------------------------------
Fax | 731-668-3425
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2043 GREYSTONE PARK
-----------------------------------------------------
City | JACKSON
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38305-3575
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 731-668-3424
-----------------------------------------------------
Fax | 731-668-3425
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. STEPHANIE PHILLIPS LAYMAN
-----------------------------------------------------
Credential | O.D.
-----------------------------------------------------
Telephone | 731-668-3424
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | ODT831
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------