Provider Demographics
NPI:1336257575
Name:POARCH BAND OF CREEK INDIANS DBA PREMIER FAMILY EYE CARE
Entity Type:Organization
Organization Name:POARCH BAND OF CREEK INDIANS DBA PREMIER FAMILY EYE CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:HEALTH ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:EDDIE
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:251-368-9136
Mailing Address - Street 1:5811 JACK SPRINGS RD.
Mailing Address - Street 2:
Mailing Address - City:ATMORE
Mailing Address - State:AL
Mailing Address - Zip Code:36502
Mailing Address - Country:US
Mailing Address - Phone:251-446-3937
Mailing Address - Fax:251-368-0805
Practice Address - Street 1:5811 JACK SPRINGS RD
Practice Address - Street 2:
Practice Address - City:ATMORE
Practice Address - State:AL
Practice Address - Zip Code:36502-5025
Practice Address - Country:US
Practice Address - Phone:251-446-3937
Practice Address - Fax:251-368-0805
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-28
Last Update Date:2017-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL529919290Medicaid
AL529919290Medicaid
5170260001Medicare NSC
ALJ780Medicare ID - Type Unspecified
AL5170260001Medicare NSC