Provider Demographics
NPI:1275721581
Name:MEDICAL CLINIC 20/20, INC
Entity Type:Organization
Organization Name:MEDICAL CLINIC 20/20, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:B
Authorized Official - Last Name:HENDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-877-9945
Mailing Address - Street 1:5301 HIGHWAY 153
Mailing Address - Street 2:
Mailing Address - City:HIXSON
Mailing Address - State:TN
Mailing Address - Zip Code:37343-4966
Mailing Address - Country:US
Mailing Address - Phone:423-875-9945
Mailing Address - Fax:423-875-9952
Practice Address - Street 1:5301 HIGHWAY 153
Practice Address - Street 2:
Practice Address - City:HIXSON
Practice Address - State:TN
Practice Address - Zip Code:37343-4966
Practice Address - Country:US
Practice Address - Phone:423-875-9945
Practice Address - Fax:423-875-9952
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-11
Last Update Date:2007-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty