Provider Demographics
NPI:1235281536
Name:TALLADEGA OPTICAL DISPENSARY LLC
Entity Type:Organization
Organization Name:TALLADEGA OPTICAL DISPENSARY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KHALID
Authorized Official - Middle Name:L
Authorized Official - Last Name:KHAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:256-362-1590
Mailing Address - Street 1:216 BATTLE ST E
Mailing Address - Street 2:
Mailing Address - City:TALLADEGA
Mailing Address - State:AL
Mailing Address - Zip Code:35160-2420
Mailing Address - Country:US
Mailing Address - Phone:256-761-1889
Mailing Address - Fax:256-362-1540
Practice Address - Street 1:216 BATTLE ST E
Practice Address - Street 2:
Practice Address - City:TALLADEGA
Practice Address - State:AL
Practice Address - Zip Code:35160-2420
Practice Address - Country:US
Practice Address - Phone:256-761-1889
Practice Address - Fax:256-362-1540
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL51512981OtherBCBS
AL4334030001Medicare ID - Type Unspecified