Provider Demographics
NPI:1649474263
Name:CLARKSVILLE EYE CLINIC LLC
Entity type:Organization
Organization Name:CLARKSVILLE EYE CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:THEODORE
Authorized Official - Last Name:DREW
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:931-645-0346
Mailing Address - Street 1:1111A FORT CAMPBELL BLVD
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37042-6426
Mailing Address - Country:US
Mailing Address - Phone:931-645-0346
Mailing Address - Fax:931-645-0348
Practice Address - Street 1:1111A FORT CAMPBELL BLVD
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37042
Practice Address - Country:US
Practice Address - Phone:931-645-0346
Practice Address - Fax:931-645-0348
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-14
Last Update Date:2019-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2519152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN5564950001Medicare NSC