MEDICARE: CAROL P. LAGRANGE, O.D., P.C.

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	ODT831	TN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	28639	OTHER	TN	BLUE CROSS & BLUE SHIELD
2	0657400001	OTHER	TN	DMERIC
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1972520807
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CAROL P. LAGRANGE, O.D., P.C.

Provider Business Mailing Address
First Line	:	2043 GREYSTONE PARK
Second Line	:
City	:	JACKSON
State	:	TN
Zip	:	38305-3575
Country	:	US
Telephone Number	:	731-668-3424
Fax Number	:	731-668-3425

Provider Business Practice Location Address
First Line	:	2043 GREYSTONE PARK
Second Line	:
City	:	JACKSON
State	:	TN
Zip	:	38305-3575
Country	:	US
Telephone Number	:	731-668-3424
Fax Number	:	731-668-3425

Authorized Official
Title or Position	:	OWNER
Name	:	DR. STEPHANIE PHILLIPS LAYMAN
Credential	:	O.D.
Telephone Number	:	731-668-3424

Provider Enumeration Date	:	07/16/2006
Last Update Date	:	08/20/2012

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