Basic Information
| Provider Information | |||||||||
| NPI: | 1881620169 | ||||||||
| 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: | 2439 N CENTRAL AVE | ||||||||
| Address2: | |||||||||
| City: | HUMBOLDT | ||||||||
| State: | TN | ||||||||
| PostalCode: | 383431753 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7317841186 | ||||||||
| FaxNumber: | 7317848228 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/25/2006 | ||||||||
| LastUpdateDate: | 09/11/2015 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LEWIS | ||||||||
| AuthorizedOfficialFirstName: | LINDY | ||||||||
| AuthorizedOfficialMiddleName: | H | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 7317841186 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | O D | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | N | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist | 332H00000X | TN | Y | Suppliers | Eyewear Supplier (Equipment, not the service) |
ID Information
| ID | Type | State | Issuer | Description | 5466560002 | 01 | TN | MEDICARE DMEPOS | OTHER | 5466560001 | 01 | TN | MEDICARE DMEPOS | OTHER | 4105755 | 01 | TN | BLUE CROSS BLUE SHIELD | OTHER | 5466560004 | 01 | TN | MEDICARE DMEPOS | OTHER | 3729980 | 05 | TN | MEDICAID | 5466560003 | 01 | TN | MEDICARE DMEPOS | OTHER |