Provider Demographics
NPI:1578890885
Name:PHILLIP B TICKNER OD & ASSOCIATES LLC
Entity Type:Organization
Organization Name:PHILLIP B TICKNER OD & ASSOCIATES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OD
Authorized Official - Prefix:
Authorized Official - First Name:PHILLIP
Authorized Official - Middle Name:BRYAN
Authorized Official - Last Name:TICKNER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:205-919-0671
Mailing Address - Street 1:109 ANDERSON CIR
Mailing Address - Street 2:
Mailing Address - City:TRUSSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35173-1001
Mailing Address - Country:US
Mailing Address - Phone:205-919-0671
Mailing Address - Fax:205-739-2027
Practice Address - Street 1:8551 WHITFIELD AVE
Practice Address - Street 2:
Practice Address - City:LEEDS
Practice Address - State:AL
Practice Address - Zip Code:35094-7560
Practice Address - Country:US
Practice Address - Phone:205-699-0719
Practice Address - Fax:205-699-0722
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-06
Last Update Date:2010-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALSB65TA769152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty