Organization
CLEVELAND OPTICAL DISPENSARY, INC.
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MR. MAURISE GENE VANDERGRIFF SR. L.D.O. (OWNER)
(423) 479-4397
Entity
Organization
Contact information
Practice address
2415 CHAMBLISS AVE NW, CLEVELAND, TN 37311-3882
(423) 479-4397
(423) 476-2974
Mailing address
2415 CHAMBLISS AVE NW, P.O. BOX 2728, CLEVELAND, TN 37311-3882
(423) 479-4397
(423) 476-2974
Taxonomy
Speciality
Code
Description
License number
State
332H00000X
Eyewear Supplier
Primary
DPO636
TN
Other
Enumeration date
01/28/2008
Last updated
01/28/2008
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