Provider Demographics
NPI:1457822421
Name:MT JULIET FAMILY VISION PC
Entity Type:Organization
Organization Name:MT JULIET FAMILY VISION PC
Other - Org Name:MT JULIET FAMILY VISION CENTER
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:615-415-0102
Mailing Address - Street 1:1005 CHARLIE DANIELS PKWY
Mailing Address - Street 2:
Mailing Address - City:MT JULIET
Mailing Address - State:TN
Mailing Address - Zip Code:37122-3391
Mailing Address - Country:US
Mailing Address - Phone:615-758-2501
Mailing Address - Fax:615-758-2524
Practice Address - Street 1:1005 CHARLIE DANIELS PARKWAY
Practice Address - Street 2:
Practice Address - City:MT JULIET
Practice Address - State:TN
Practice Address - Zip Code:37122-3391
Practice Address - Country:US
Practice Address - Phone:615-758-2501
Practice Address - Fax:615-758-2524
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-12-17
Last Update Date:2021-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3286OtherTN BOARD OF OPTOMETRY