Provider Demographics
NPI:1417968389
Name:INSTITUTE FOR TOTAL EYE CARE
Entity Type:Organization
Organization Name:INSTITUTE FOR TOTAL EYE CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:R
Authorized Official - Last Name:YONKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:334-277-9111
Mailing Address - Street 1:4255 CARMICHAEL CT N
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36106-2875
Mailing Address - Country:US
Mailing Address - Phone:334-277-9111
Mailing Address - Fax:334-270-9359
Practice Address - Street 1:4255 CARMICHAEL CT N
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36106-2875
Practice Address - Country:US
Practice Address - Phone:334-277-9111
Practice Address - Fax:334-270-9359
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:INSTITUTE FOR TOTAL EYE CARE, P.C.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-08-10
Last Update Date:2009-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL529002290Medicaid
ALG289Medicare PIN
AL529002290Medicaid