Provider Demographics
NPI:1447420021
Name:PROFESSIONAL OPTICIANS
Entity type:Organization
Organization Name:PROFESSIONAL OPTICIANS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:FREDIE
Authorized Official - Middle Name:CECIL
Authorized Official - Last Name:FROST
Authorized Official - Suffix:
Authorized Official - Credentials:LDO
Authorized Official - Phone:423-894-1947
Mailing Address - Street 1:5726 MARLIN RD
Mailing Address - Street 2:STE 102
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37411-4008
Mailing Address - Country:US
Mailing Address - Phone:423-894-1947
Mailing Address - Fax:423-894-1947
Practice Address - Street 1:5726 MARLIN RD
Practice Address - Street 2:STE 102
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37411-4008
Practice Address - Country:US
Practice Address - Phone:423-894-1947
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-10
Last Update Date:2008-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDPO218332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN5095850001Medicare PIN
TN5095850001Medicare NSC