Provider Demographics
NPI:1902220502
Name:OOLTEWAH VISION CENTER PLLC
Entity Type:Organization
Organization Name:OOLTEWAH VISION CENTER PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:E
Authorized Official - Last Name:MULLINS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:423-910-0412
Mailing Address - Street 1:5958 SNOW HILL RD
Mailing Address - Street 2:SUITE 136
Mailing Address - City:OOLTEWAH
Mailing Address - State:TN
Mailing Address - Zip Code:37363-7833
Mailing Address - Country:US
Mailing Address - Phone:423-910-0412
Mailing Address - Fax:423-910-0426
Practice Address - Street 1:5958 SNOW HILL RD
Practice Address - Street 2:SUITE 136
Practice Address - City:OOLTEWAH
Practice Address - State:TN
Practice Address - Zip Code:37363-7833
Practice Address - Country:US
Practice Address - Phone:423-910-0412
Practice Address - Fax:423-910-0426
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-18
Last Update Date:2014-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNOD0000002639152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN39470471Medicaid
TN39470471Medicaid