=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972754901
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DAVID L FOUTCH OD PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/08/2008
-----------------------------------------------------
Last Update Date | 05/22/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2585 NASHVILLE HWY
-----------------------------------------------------
City | SMITHVILLE
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37166-7259
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 615-597-2255
-----------------------------------------------------
Fax | 615-597-2257
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2585 NASHVILLE HWY
-----------------------------------------------------
City | SMITHVILLE
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37166-7259
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 615-597-2255
-----------------------------------------------------
Fax | 615-597-2257
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. DAVID L FOUTCH
-----------------------------------------------------
Credential | OD PC
-----------------------------------------------------
Telephone | 615-597-2255
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | ODT1164
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------