Basic Information
| Provider Information | |||||||||
| NPI: | 1730106220 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | EYE CARE GROUP, PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 509 | ||||||||
| Address2: | |||||||||
| City: | HUMBOLDT | ||||||||
| State: | TN | ||||||||
| PostalCode: | 383430509 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7317841186 | ||||||||
| FaxNumber: | 7317848228 | ||||||||
| Practice Location | |||||||||
| Address1: | 2439 N CENTRAL AVE | ||||||||
| Address2: | |||||||||
| City: | HUMBOLDT | ||||||||
| State: | TN | ||||||||
| PostalCode: | 383431753 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7317841186 | ||||||||
| FaxNumber: | 7317848228 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2006 | ||||||||
| LastUpdateDate: | 05/15/2008 | ||||||||
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| AuthorizedOfficialLastName: | AGEE | ||||||||
| AuthorizedOfficialFirstName: | PHILLIP | ||||||||
| AuthorizedOfficialMiddleName: | EARL | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 7317841186 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | EYE CARE GROUP, PLLC | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | O D | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332H00000X | Y | Suppliers | Eyewear Supplier (Equipment, not the service) |
ID Information
| ID | Type | State | Issuer | Description | 4105755 | 01 | TN | BLUE CROSS BLUE SHIELD | OTHER |