Provider Demographics
NPI:1912018144
Name:SOUTHERN FAMILY OPTOMETRY P.C.
Entity Type:Organization
Organization Name:SOUTHERN FAMILY OPTOMETRY P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:HA
Authorized Official - Middle Name:THI
Authorized Official - Last Name:NGUYEN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:901-517-8178
Mailing Address - Street 1:PO BOX 252
Mailing Address - Street 2:
Mailing Address - City:FULTONDALE
Mailing Address - State:AL
Mailing Address - Zip Code:35068-0252
Mailing Address - Country:US
Mailing Address - Phone:901-517-8178
Mailing Address - Fax:
Practice Address - Street 1:690 HIGHWAY 78
Practice Address - Street 2:
Practice Address - City:SUMITON
Practice Address - State:AL
Practice Address - Zip Code:35148-3419
Practice Address - Country:US
Practice Address - Phone:205-648-0371
Practice Address - Fax:205-648-0308
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALSB11TA697152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALV07128Medicare UPIN