Provider Demographics
NPI:1043477680
Name:DICKSON OPTICAL PC
Entity type:Organization
Organization Name:DICKSON OPTICAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:ROSIE
Authorized Official - Middle Name:G
Authorized Official - Last Name:BRADFORD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-446-8089
Mailing Address - Street 1:110 MATHIS DR
Mailing Address - Street 2:SUITE 108
Mailing Address - City:DICKSON
Mailing Address - State:TN
Mailing Address - Zip Code:37055-2000
Mailing Address - Country:US
Mailing Address - Phone:615-441-9996
Mailing Address - Fax:615-441-3135
Practice Address - Street 1:110 MATHIS DR
Practice Address - Street 2:SUITE 108
Practice Address - City:DICKSON
Practice Address - State:TN
Practice Address - Zip Code:37055-2000
Practice Address - Country:US
Practice Address - Phone:615-441-9996
Practice Address - Fax:615-441-3135
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-21
Last Update Date:2008-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN0393090004Medicare NSC
TN3940136Medicare PIN