Provider Demographics
NPI:1720142771
Name:SULLINS EYE CARE P.C.
Entity Type:Organization
Organization Name:SULLINS EYE CARE P.C.
Other - Org Name:SULLINS EYE CARE P.C.
Other - Org Type:Other Name
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTA
Authorized Official - Middle Name:H
Authorized Official - Last Name:SULLINS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:423-442-2806
Mailing Address - Street 1:PO BOX 247
Mailing Address - Street 2:
Mailing Address - City:MADISONVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37354-0247
Mailing Address - Country:US
Mailing Address - Phone:423-442-2806
Mailing Address - Fax:
Practice Address - Street 1:620 ENGLEWOOD RD
Practice Address - Street 2:
Practice Address - City:MADISONVILLE
Practice Address - State:TN
Practice Address - Zip Code:37354-1218
Practice Address - Country:US
Practice Address - Phone:423-442-2806
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-21
Last Update Date:2007-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNOD0000001689152W00000X
TNOD0000001899152W00000X
TNOD0000001722152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3590906OtherMEDICARE
TN3569362Medicare PIN