Provider Demographics
NPI:1114040409
Name:DRS. FORTNER AND YATES
Entity Type:Organization
Organization Name:DRS. FORTNER AND YATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:YATES
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:731-855-0811
Mailing Address - Street 1:PO BOX 88
Mailing Address - Street 2:
Mailing Address - City:TRENTON
Mailing Address - State:TN
Mailing Address - Zip Code:38382-0088
Mailing Address - Country:US
Mailing Address - Phone:731-855-0811
Mailing Address - Fax:731-855-4725
Practice Address - Street 1:107 E 1ST ST
Practice Address - Street 2:
Practice Address - City:TRENTON
Practice Address - State:TN
Practice Address - Zip Code:38382-1841
Practice Address - Country:US
Practice Address - Phone:731-855-0811
Practice Address - Fax:731-855-4725
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-09
Last Update Date:2008-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNODT435 AND ODT1590152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3599677Medicare PIN
TN0455670001Medicare NSC