MEDICARE: BLACKERBY EYE CARE, 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	152W00000X	Optometrist	SC58TA896	AL

General Provider Information

NPI Number	:	1669711651
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BLACKERBY EYE CARE, LLC

Provider Business Mailing Address
First Line	:	PO BOX 265
Second Line	:
City	:	SHELBY
State	:	AL
Zip	:	35143-0265
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	7201 AARON ARONOV DR
Second Line	:
City	:	FAIRFIELD
State	:	AL
Zip	:	35064-1831
Country	:	US
Telephone Number	:	205-923-4377
Fax Number	:	205-923-4960

Authorized Official
Title or Position	:	OPTOMETRIST/OWNER
Name	:	JOHNNA LEIGH HEADLEY BLACKERBY
Credential	:	O.D.
Telephone Number	:	205-337-8715

Provider Enumeration Date	:	02/11/2013
Last Update Date	:	02/11/2013

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Directions to “BLACKERBY EYE CARE, LLC ” Practice Location

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