Provider Demographics
NPI:1295868040
Name:SPECKS 'N SHADES VISION CENTER INC.
Entity type:Organization
Organization Name:SPECKS 'N SHADES VISION CENTER INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:S
Authorized Official - Last Name:BOLES
Authorized Official - Suffix:
Authorized Official - Credentials:LDO
Authorized Official - Phone:423-247-9192
Mailing Address - Street 1:1001 E STONE DR
Mailing Address - Street 2:
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37660-3383
Mailing Address - Country:US
Mailing Address - Phone:423-247-9192
Mailing Address - Fax:423-245-1017
Practice Address - Street 1:1001 E STONE DR
Practice Address - Street 2:
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-3383
Practice Address - Country:US
Practice Address - Phone:423-247-9192
Practice Address - Fax:423-245-1017
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDPO0000000180156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty