Provider Demographics
NPI:1427297472
Name:SIMONTON EYE CARE CLINIC
Entity type:Organization
Organization Name:SIMONTON EYE CARE CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIC ASSISTANT
Authorized Official - Prefix:MRS
Authorized Official - First Name:KRISTINA
Authorized Official - Middle Name:L
Authorized Official - Last Name:BREEDEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-672-4683
Mailing Address - Street 1:2823 HIGHWAY 31 W # SOUTH
Mailing Address - Street 2:
Mailing Address - City:WHITE HOUSE
Mailing Address - State:TN
Mailing Address - Zip Code:37188-5241
Mailing Address - Country:US
Mailing Address - Phone:615-672-4683
Mailing Address - Fax:615-672-4643
Practice Address - Street 1:2823 HIGHWAY 31 W # SOUTH
Practice Address - Street 2:
Practice Address - City:WHITE HOUSE
Practice Address - State:TN
Practice Address - Zip Code:37188-5241
Practice Address - Country:US
Practice Address - Phone:615-672-4683
Practice Address - Fax:615-672-4643
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-16
Last Update Date:2015-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNTN0759261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNU23770Medicare UPIN
TN3594618Medicare PIN
TN0993660001Medicare NSC