MEDICARE: TALLADEGA OPTICAL DISPENSARY LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	156FX1800X	Optician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	51512981	OTHER	AL	BCBS

General Provider Information

NPI Number	:	1235281536
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TALLADEGA OPTICAL DISPENSARY LLC

Provider Business Mailing Address
First Line	:	216 BATTLE ST E
Second Line	:
City	:	TALLADEGA
State	:	AL
Zip	:	35160-2420
Country	:	US
Telephone Number	:	256-761-1889
Fax Number	:	256-362-1540

Provider Business Practice Location Address
First Line	:	216 BATTLE ST E
Second Line	:
City	:	TALLADEGA
State	:	AL
Zip	:	35160-2420
Country	:	US
Telephone Number	:	256-761-1889
Fax Number	:	256-362-1540

Authorized Official
Title or Position	:	OWNER
Name	:	DR. KHALID L KHAN
Credential	:	M.D.
Telephone Number	:	256-362-1590

Provider Enumeration Date	:	01/17/2007
Last Update Date	:	08/22/2020

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Directions to “TALLADEGA OPTICAL DISPENSARY LLC ” Practice Location

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