Provider Demographics
NPI:1528233764
Name:KENNETH W. NIX, O.D.
Entity type:Organization
Organization Name:KENNETH W. NIX, O.D.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANN
Authorized Official - Middle Name:
Authorized Official - Last Name:VANDYKEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-949-3937
Mailing Address - Street 1:PO BOX 1449
Mailing Address - Street 2:
Mailing Address - City:DUNLAP
Mailing Address - State:TN
Mailing Address - Zip Code:37327-1449
Mailing Address - Country:US
Mailing Address - Phone:423-949-3937
Mailing Address - Fax:423-949-7435
Practice Address - Street 1:15247 RANKIN AVE
Practice Address - Street 2:
Practice Address - City:DUNLAP
Practice Address - State:TN
Practice Address - Zip Code:37327
Practice Address - Country:US
Practice Address - Phone:423-949-3937
Practice Address - Fax:423-949-7435
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-29
Last Update Date:2008-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNODT617152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3594241Medicaid
TN0243860001Medicare NSC
TN3594241Medicaid
TNT61179Medicare UPIN