Provider Demographics
NPI:1396890455
Name:MCLENDON & SONS OPTICAL 2
Entity type:Organization
Organization Name:MCLENDON & SONS OPTICAL 2
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:KENNON
Authorized Official - Last Name:BERRY
Authorized Official - Suffix:SR
Authorized Official - Credentials:OD
Authorized Official - Phone:256-314-1125
Mailing Address - Street 1:PO BOX 3781
Mailing Address - Street 2:
Mailing Address - City:MUSCLE SHOALS
Mailing Address - State:AL
Mailing Address - Zip Code:35662-3781
Mailing Address - Country:US
Mailing Address - Phone:256-314-1125
Mailing Address - Fax:
Practice Address - Street 1:725 STATE ST
Practice Address - Street 2:
Practice Address - City:MUSCLE SHOALS
Practice Address - State:AL
Practice Address - Zip Code:35661-2939
Practice Address - Country:US
Practice Address - Phone:256-314-1125
Practice Address - Fax:256-381-2323
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:RUSS OPTICAL SUPERSTORE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-01-25
Last Update Date:2007-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALS425TA230152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL1528014495OtherINDIVIDUAL NPI
AL1396890455OtherORGANIZATIONAL NPI
ALT69128Medicare UPIN