Provider Demographics
NPI:1437255122
Name:KING, RANEE BERNICE (LICENSED OPTICAN)
Entity Type:Individual
Prefix:
First Name:RANEE
Middle Name:BERNICE
Last Name:KING
Suffix:
Gender:F
Credentials:LICENSED OPTICAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1240 FOX MEADOWS BLVD
Mailing Address - Street 2:SUITE 2
Mailing Address - City:SEVIERVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37862-6928
Mailing Address - Country:US
Mailing Address - Phone:865-453-5068
Mailing Address - Fax:865-453-4987
Practice Address - Street 1:1240 FOX MEADOWS BLVD
Practice Address - Street 2:SUITE 2
Practice Address - City:SEVIERVILLE
Practice Address - State:TN
Practice Address - Zip Code:37862-6928
Practice Address - Country:US
Practice Address - Phone:865-453-5068
Practice Address - Fax:865-453-4987
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-16
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN654156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4503990001Medicare ID - Type UnspecifiedMEDICARE PALMETTO GBA