Provider Demographics
NPI:1629133111
Name:ANDALUSIA EYE CLINIC LLC
Entity Type:Organization
Organization Name:ANDALUSIA EYE CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:H
Authorized Official - Last Name:TILLMAN
Authorized Official - Suffix:JR
Authorized Official - Credentials:OD
Authorized Official - Phone:334-222-2020
Mailing Address - Street 1:PO BOX 1517
Mailing Address - Street 2:
Mailing Address - City:ANDALUSIA
Mailing Address - State:AL
Mailing Address - Zip Code:36420-1226
Mailing Address - Country:US
Mailing Address - Phone:334-222-2020
Mailing Address - Fax:
Practice Address - Street 1:1860 E THREE NOTCH ST
Practice Address - Street 2:
Practice Address - City:ANDALUSIA
Practice Address - State:AL
Practice Address - Zip Code:36421-2404
Practice Address - Country:US
Practice Address - Phone:334-222-2020
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-26
Last Update Date:2015-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALS620TA088152W00000X
AL00025149207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALT69089Medicare UPIN
ALH81609Medicare UPIN