Basic Information
| Provider Information | |||||||||
| NPI: | 1558403568 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | JEMISON EYE CARE LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 730 | ||||||||
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| City: | JEMISON | ||||||||
| State: | AL | ||||||||
| PostalCode: | 350850730 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2056881010 | ||||||||
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| Practice Location | |||||||||
| Address1: | 24810 US HIGHWAY 31 | ||||||||
| Address2: | |||||||||
| City: | JEMISON | ||||||||
| State: | AL | ||||||||
| PostalCode: | 350857876 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2056881010 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/13/2007 | ||||||||
| LastUpdateDate: | 06/03/2014 | ||||||||
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| AuthorizedOfficialLastName: | GREEN | ||||||||
| AuthorizedOfficialFirstName: | LISA | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | CHAIRMAN OF BOARD OF DIRECTORS | ||||||||
| AuthorizedOfficialTelephone: | 2056881010 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | O.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | S-A35-TA-588 | AL | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 510G700150 | 01 | AL | MEDICARE PTAN | OTHER | 529912640 | 05 | AL | MEDICAID |