Provider Demographics
NPI:1124062856
Name:BALMER, LORI HUSKINS (OD)
Entity type:Individual
Prefix:
First Name:LORI
Middle Name:HUSKINS
Last Name:BALMER
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3103 OCOEE ST N
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:TN
Mailing Address - Zip Code:37312-5381
Mailing Address - Country:US
Mailing Address - Phone:423-479-4174
Mailing Address - Fax:
Practice Address - Street 1:3103 OCOEE ST N
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:TN
Practice Address - Zip Code:37312-5381
Practice Address - Country:US
Practice Address - Phone:423-479-4174
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-15
Last Update Date:2012-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNOD1572152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN2240040OtherUNITED HEALTH CARE
TN6985019OtherCIGNA
TN3036748OtherBLUE CROSS BLUE SHIELD
TN1119050001OtherMEDICARE PALMETTO GOVERNM
TNU53198Medicare UPIN
TN1119050001OtherMEDICARE PALMETTO GOVERNM