Basic Information
Provider Information | |||||||||
NPI: | 1831128768 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | EYE CARE GROUP, PLLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 509 | ||||||||
Address2: |   | ||||||||
City: | HUMBOLDT | ||||||||
State: | TN | ||||||||
PostalCode: | 383430509 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7317841186 | ||||||||
FaxNumber: | 7317848228 | ||||||||
Practice Location | |||||||||
Address1: | 2300 AMANDA AVE | ||||||||
Address2: |   | ||||||||
City: | DYERSBURG | ||||||||
State: | TN | ||||||||
PostalCode: | 380241961 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7312861002 | ||||||||
FaxNumber: | 7312866231 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/02/2006 | ||||||||
LastUpdateDate: | 05/15/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
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 |