Basic Information
| Provider Information | |||||||||
| NPI: | 1538179866 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ENTERPRISE OPTICAL LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 812 E. LEE | ||||||||
| Address2: | |||||||||
| City: | ENTERPRISE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 36330 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3343932020 | ||||||||
| FaxNumber: | 3343936936 | ||||||||
| Practice Location | |||||||||
| Address1: | 812 E. LEE | ||||||||
| Address2: | |||||||||
| City: | ENTERPRISE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 36330 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3343932020 | ||||||||
| FaxNumber: | 3343936936 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2006 | ||||||||
| LastUpdateDate: | 03/21/2008 | ||||||||
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| AuthorizedOfficialLastName: | WOODS | ||||||||
| AuthorizedOfficialFirstName: | LORIE | ||||||||
| AuthorizedOfficialMiddleName: | C. | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 3343932020 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | O.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 111905 | 01 | AL | EYEMED | OTHER | 51004506 | 01 | AL | BLUE CROSS BLUE SHIELD | OTHER |