Provider Demographics
NPI:1518467778
Name:K&M OPTICAL
Entity Type:Organization
Organization Name:K&M OPTICAL
Other - Org Name:VISIONARY EYEWORKS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SAMANTHA
Authorized Official - Middle Name:
Authorized Official - Last Name:PERRONE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:931-436-0555
Mailing Address - Street 1:73 WHITE BRIDGE RD STE 105
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37205-1444
Mailing Address - Country:US
Mailing Address - Phone:615-353-0434
Mailing Address - Fax:615-352-6080
Practice Address - Street 1:73 WHITE BRIDGE RD STE 105
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37205-1444
Practice Address - Country:US
Practice Address - Phone:615-353-0434
Practice Address - Fax:615-352-6080
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-14
Last Update Date:2018-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2719152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ033960Medicaid