Provider Demographics
NPI:1982684106
Name:MT JULIET FAMILY VISION CENTER
Entity Type:Organization
Organization Name:MT JULIET FAMILY VISION CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:K
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:615-758-2501
Mailing Address - Street 1:830 N MOUNT JULIET RD
Mailing Address - Street 2:
Mailing Address - City:MOUNT JULIET
Mailing Address - State:TN
Mailing Address - Zip Code:37122-3391
Mailing Address - Country:US
Mailing Address - Phone:615-758-2501
Mailing Address - Fax:615-758-2524
Practice Address - Street 1:830 N MOUNT JULIET RD
Practice Address - Street 2:
Practice Address - City:MOUNT JULIET
Practice Address - State:TN
Practice Address - Zip Code:37122-3391
Practice Address - Country:US
Practice Address - Phone:615-758-2501
Practice Address - Fax:615-758-2524
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-23
Last Update Date:2008-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1166152W00000X
TN1157152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN0383880001Medicare NSC
TN3597394Medicare PIN
TNCA5814Medicare PIN