Provider Demographics
NPI:1700816949
Name:FAIRBANKS OCULAR PROSTHETICS, INC.
Entity Type:Organization
Organization Name:FAIRBANKS OCULAR PROSTHETICS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:E
Authorized Official - Last Name:SANDERS
Authorized Official - Suffix:
Authorized Official - Credentials:BCO, BADO
Authorized Official - Phone:615-322-9940
Mailing Address - Street 1:1720 WEST END AVE
Mailing Address - Street 2:SUITE 402
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37203
Mailing Address - Country:US
Mailing Address - Phone:615-322-9940
Mailing Address - Fax:615-320-0970
Practice Address - Street 1:1720 WEST END AVE
Practice Address - Street 2:SUITE 402
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37203
Practice Address - Country:US
Practice Address - Phone:615-322-9940
Practice Address - Fax:615-320-0970
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN05-311-11156FX1700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1700XEye and Vision Services ProvidersTechnician/TechnologistOcularistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1452191Medicaid
KY90262916Medicaid
TN0985120001Medicare NSC