Provider Demographics
NPI:1245490630
Name:DALE HASTY
Entity type:Organization
Organization Name:DALE HASTY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:DALE
Authorized Official - Last Name:HASTY
Authorized Official - Suffix:
Authorized Official - Credentials:O D
Authorized Official - Phone:934-684-2020
Mailing Address - Street 1:605 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SHELBYVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37160-3210
Mailing Address - Country:US
Mailing Address - Phone:931-684-2020
Mailing Address - Fax:931-684-7000
Practice Address - Street 1:605 N MAIN ST
Practice Address - Street 2:
Practice Address - City:SHELBYVILLE
Practice Address - State:TN
Practice Address - Zip Code:37160-3210
Practice Address - Country:US
Practice Address - Phone:931-684-2020
Practice Address - Fax:931-684-7000
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-10
Last Update Date:2008-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNODT001018152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN0752740001OtherPALMETTO
TN0075676OtherBCBS
TN0752740001OtherPALMETTO
TN3596423Medicare PIN