Basic Information
| Provider Information | |||||||||
| NPI: | 1669513354 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | D-FOUR INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | PEARLE VISION | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1701 MCFARLAND BLVD E | ||||||||
| Address2: | 121 UNIVERSITY MALL | ||||||||
| City: | TUSCALOOSA | ||||||||
| State: | AL | ||||||||
| PostalCode: | 354045824 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2055562490 | ||||||||
| FaxNumber: | 2055568299 | ||||||||
| Practice Location | |||||||||
| Address1: | 1701 MCFARLAND BLVD E | ||||||||
| Address2: | 121 UNIVERSITY MALL | ||||||||
| City: | TUSCALOOSA | ||||||||
| State: | AL | ||||||||
| PostalCode: | 354045824 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2055562490 | ||||||||
| FaxNumber: | 2055568299 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/08/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | DEFORD | ||||||||
| AuthorizedOfficialFirstName: | WILMA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2055562490 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
ID Information
| ID | Type | State | Issuer | Description | 510-59763 | 01 | AL | BLUE CROSS-BLUE SHIELD | OTHER |