Provider Demographics
NPI:1699881565
Name:NIX, KENNETH
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:NIX
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1449
Mailing Address - Street 2:
Mailing Address - City:DUNLAP
Mailing Address - State:TN
Mailing Address - Zip Code:37327
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
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-22
Last Update Date:2012-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNODT617152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3594241Medicaid
TNT61179Medicare UPIN
TN3594241Medicaid
TN0243860001Medicare NSC