Provider Demographics
NPI:1316012099
Name:OPTOMETRIC CENTER PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:OPTOMETRIC CENTER PROFESSIONAL CORPORATION
Other - Org Name:OPTOMETRIC CENTER PC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:EDWIN
Authorized Official - Middle Name:G
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:731-364-2150
Mailing Address - Street 1:113 EAST LOCUST ST
Mailing Address - Street 2:
Mailing Address - City:DRESDEN
Mailing Address - State:TN
Mailing Address - Zip Code:38225-0031
Mailing Address - Country:US
Mailing Address - Phone:731-364-2150
Mailing Address - Fax:731-364-5157
Practice Address - Street 1:113 E LOCUST ST
Practice Address - Street 2:
Practice Address - City:DRESDEN
Practice Address - State:TN
Practice Address - Zip Code:38225-1440
Practice Address - Country:US
Practice Address - Phone:731-364-2150
Practice Address - Fax:731-364-5157
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:OPTOMETRIC CENTER PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-11-21
Last Update Date:2021-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNODT241152W00000X
152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3595130Medicare PIN
TN0714210001Medicare NSC