Provider Demographics
NPI:1730201831
Name:GREENEVILLE EYE CLINIC OPTICAL SHOP
Entity type:Organization
Organization Name:GREENEVILLE EYE CLINIC OPTICAL SHOP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:JACKSON
Authorized Official - Last Name:SMEAD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:423-639-6454
Mailing Address - Street 1:801 E CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:GREENEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37745-6219
Mailing Address - Country:US
Mailing Address - Phone:423-639-6454
Mailing Address - Fax:423-787-7210
Practice Address - Street 1:801 E CHURCH ST
Practice Address - Street 2:
Practice Address - City:GREENEVILLE
Practice Address - State:TN
Practice Address - Zip Code:37745-6219
Practice Address - Country:US
Practice Address - Phone:423-639-6454
Practice Address - Fax:423-787-7210
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN0134083OtherBCBS PROVIDER #
TN0402320001Medicare ID - Type UnspecifiedMEDICARE PROVIDER #