Organization
SULLINS EYE CARE CENTER, INC.
Active
Organization subpart
No
Provider details
NPI number
Authorized official
LYNNE TIDWELL (BUSINESS MANAGER)
(256) 464-6670
Entity
Organization
Contact information
Practice address
104 GIN OAKS CT, MADISON, AL 35758-1736
(256) 464-6670
(256) 464-6670
Mailing address
104 GIN OAKS CT, MADISON, AL 35758-1736
(256) 464-6670
(256) 464-6670
Taxonomy
Speciality
Code
Description
License number
State
152W00000X
Optometrist
Primary
S-761-TA-167
AL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
529923030
MEDICAID GROUP PIN
AL
01
—
K232
MEDICARE GROUP PIN
AL
01
—
Q949
BCBS OF ALABAMA GROUP PIN
AL
Enumeration date
11/15/2007
Last updated
11/21/2012
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