Provider Demographics
NPI:1609066703
Name:LIGHTHOUSE OPTICAL OF TENNESSEE, LLC
Entity Type:Organization
Organization Name:LIGHTHOUSE OPTICAL OF TENNESSEE, LLC
Other - Org Name:HORNER RAUSCH SUPER OPTICAL OF COOKEVILLE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OPTOMETRIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:MORGAN
Authorized Official - Last Name:RICHARDSON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:931-528-6411
Mailing Address - Street 1:430 NEAL ST
Mailing Address - Street 2:
Mailing Address - City:COOKEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38501-0916
Mailing Address - Country:US
Mailing Address - Phone:931-528-6411
Mailing Address - Fax:931-372-0380
Practice Address - Street 1:430 NEAL ST
Practice Address - Street 2:
Practice Address - City:COOKEVILLE
Practice Address - State:TN
Practice Address - Zip Code:38501-0916
Practice Address - Country:US
Practice Address - Phone:931-528-6411
Practice Address - Fax:931-372-0380
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-26
Last Update Date:2023-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNOD T-1155152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3087067OtherBLUE CROSS BLUE SHIELD TN
TN3945214OtherGROUP PROVIDER NUMBER
TN3596618Medicaid
TN3596618Medicaid
TN410047014Medicare PIN