Provider Demographics
NPI:1518155381
Name:DECATUR OPTICAL DISPENSARY
Entity Type:Organization
Organization Name:DECATUR OPTICAL DISPENSARY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRES. OF COMPANY/OPTICIAN
Authorized Official - Prefix:MR
Authorized Official - First Name:JACK
Authorized Official - Middle Name:L
Authorized Official - Last Name:HOLBERT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:256-351-0040
Mailing Address - Street 1:201 6TH AVE SE
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:AL
Mailing Address - Zip Code:35601-3115
Mailing Address - Country:US
Mailing Address - Phone:256-351-0040
Mailing Address - Fax:256-301-0449
Practice Address - Street 1:201 6TH AVE SE
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:AL
Practice Address - Zip Code:35601-3115
Practice Address - Country:US
Practice Address - Phone:256-351-0040
Practice Address - Fax:256-301-0449
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-05
Last Update Date:2015-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL332H00000X332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
1629014469OtherNPI