Provider Demographics
NPI:1942426390
Name:CAROL J. BALLARD OD
Entity Type:Organization
Organization Name:CAROL J. BALLARD OD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:J
Authorized Official - Last Name:BALLARD
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:931-729-2190
Mailing Address - Street 1:205 1/2 E PUBLIC SQ
Mailing Address - Street 2:
Mailing Address - City:CENTERVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37033-1601
Mailing Address - Country:US
Mailing Address - Phone:931-729-2190
Mailing Address - Fax:931-729-2805
Practice Address - Street 1:205 1/2 E PUBLIC SQ
Practice Address - Street 2:
Practice Address - City:CENTERVILLE
Practice Address - State:TN
Practice Address - Zip Code:37033-1601
Practice Address - Country:US
Practice Address - Phone:931-729-2190
Practice Address - Fax:931-729-2805
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-17
Last Update Date:2016-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNOD807152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3941070Medicaid
TN0275800001Medicare NSC
TN0275800001Medicare NSC