Provider Demographics
NPI:1093975021
Name:20/20 OPTICAL LLC
Entity Type:Organization
Organization Name:20/20 OPTICAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:GENE
Authorized Official - Middle Name:A
Authorized Official - Last Name:WILLIFORD
Authorized Official - Suffix:
Authorized Official - Credentials:DPO
Authorized Official - Phone:423-899-3930
Mailing Address - Street 1:7268 JARNIGAN RD
Mailing Address - Street 2:SUITE 304
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37421-3096
Mailing Address - Country:US
Mailing Address - Phone:423-899-3930
Mailing Address - Fax:423-899-1590
Practice Address - Street 1:7268 JARNIGAN RD
Practice Address - Street 2:SUITE 304
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37421-3096
Practice Address - Country:US
Practice Address - Phone:423-899-3930
Practice Address - Fax:423-899-1590
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-12
Last Update Date:2008-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNTN0291332900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332900000XSuppliersNon-Pharmacy Dispensing Site
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN6142140001Medicare NSC