Provider Demographics
NPI:1760652291
Name:JACK RABY OPTICAL
Entity Type:Organization
Organization Name:JACK RABY OPTICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JACK
Authorized Official - Middle Name:W
Authorized Official - Last Name:RABY
Authorized Official - Suffix:II
Authorized Official - Credentials:LDO
Authorized Official - Phone:865-982-5317
Mailing Address - Street 1:343 GILL ST
Mailing Address - Street 2:
Mailing Address - City:ALCOA
Mailing Address - State:TN
Mailing Address - Zip Code:37701-2415
Mailing Address - Country:US
Mailing Address - Phone:865-982-5317
Mailing Address - Fax:865-982-5935
Practice Address - Street 1:343 GILL ST
Practice Address - Street 2:
Practice Address - City:ALCOA
Practice Address - State:TN
Practice Address - Zip Code:37701-2415
Practice Address - Country:US
Practice Address - Phone:865-982-5317
Practice Address - Fax:865-982-5935
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-12
Last Update Date:2008-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDPO 446332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1295490001Medicare NSC