Individual
MR. MAURISE GENE VANDERGRIFF SR.
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
L.D.O.
Contact information
Practice address
2415 CHAMBLISS AVE NW, CLEVELAND, TN 37311-3882
(423) 479-4397
(423) 476-2974
Mailing address
2415 CHAMBLISS AVE NW, CLEVELAND, TN 37311-3882
(423) 479-4397
(423) 476-2974
Taxonomy
Speciality
Code
Description
License number
State
156FX1800X
Optician
Primary
DPO 319
TN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
2002794
BLUE CROSS & BLUE SHIELD
TN
Enumeration date
02/26/2007
Last updated
03/06/2008
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