Provider Demographics
NPI:1962618520
Name:BALLARD, VICKI L (ABOC)
Entity type:Individual
Prefix:
First Name:VICKI
Middle Name:L
Last Name:BALLARD
Suffix:
Gender:F
Credentials:ABOC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:832 TANKERSLEY RD
Mailing Address - Street 2:
Mailing Address - City:KELLYTON
Mailing Address - State:AL
Mailing Address - Zip Code:35089-4314
Mailing Address - Country:US
Mailing Address - Phone:256-409-2201
Mailing Address - Fax:
Practice Address - Street 1:32 MAIN ST
Practice Address - Street 2:
Practice Address - City:ALEX CITY
Practice Address - State:AL
Practice Address - Zip Code:35010-1904
Practice Address - Country:US
Practice Address - Phone:256-409-2322
Practice Address - Fax:256-409-2321
Is Sole Proprietor?:No
Enumeration Date:2007-05-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL157927156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician