MEDICARE: MR. JIMMY EARL CRITTENDEN OPTICIAN

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	LDO000424	GA

General Provider Information

NPI Number	:	1548394703
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JIMMY EARL CRITTENDEN OPTICIAN

Provider Business Mailing Address
First Line	:	1413 DOSSETT ST
Second Line	:
City	:	ATHENS
State	:	TN
Zip	:	37303-4455
Country	:	US
Telephone Number	:	423-746-8806
Fax Number	:

Provider Business Practice Location Address
First Line	:	1281 BATTLEFIELD PKWY
Second Line	:
City	:	FORT OGLETHORPE
State	:	GA
Zip	:	30742-4009
Country	:	US
Telephone Number	:	706-861-7053
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/16/2007
Last Update Date	:	07/08/2007

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