Basic Information
| Provider Information | |||||||||
| NPI: | 1952558249 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PERFECT OPTICAL EYECARE CENTER LLC | ||||||||
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| OtherOrganizationName: | PERFECT OPTICAL EYECARE CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6945 UNIVERSITY DR NW | ||||||||
| Address2: | SUITE G | ||||||||
| City: | HUNTSVILLE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 358061786 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2563256950 | ||||||||
| FaxNumber: | 2565851019 | ||||||||
| Practice Location | |||||||||
| Address1: | 6945 UNIVERSITY DR NW | ||||||||
| Address2: | SUITE G | ||||||||
| City: | HUNTSVILLE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 358061786 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2563256950 | ||||||||
| FaxNumber: | 2565851019 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/19/2008 | ||||||||
| LastUpdateDate: | 11/24/2015 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BAGLEY | ||||||||
| AuthorizedOfficialFirstName: | DANE | ||||||||
| AuthorizedOfficialMiddleName: | WILLIAM | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER AND DOCTOR | ||||||||
| AuthorizedOfficialTelephone: | 2563256950 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | O.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | S-981-TA-566 | AL | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 529926980 | 05 | AL | MEDICAID |