Provider Demographics
NPI:1578744868
Name:SULLINS EYE CARE CENTER, INC.
Entity Type:Organization
Organization Name:SULLINS EYE CARE CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LYNNE
Authorized Official - Middle Name:
Authorized Official - Last Name:TIDWELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:256-464-6670
Mailing Address - Street 1:104 GIN OAKS CT
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:AL
Mailing Address - Zip Code:35758-1736
Mailing Address - Country:US
Mailing Address - Phone:256-464-6670
Mailing Address - Fax:256-464-6670
Practice Address - Street 1:104 GIN OAKS CT
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:AL
Practice Address - Zip Code:35758-1736
Practice Address - Country:US
Practice Address - Phone:256-464-6670
Practice Address - Fax:256-464-6670
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-15
Last Update Date:2012-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALS-761-TA-167152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALK232OtherMEDICARE GROUP PIN
ALQ949OtherBCBS OF ALABAMA GROUP PIN
AL529923030OtherMEDICAID GROUP PIN
ALK232OtherMEDICARE GROUP PIN