Provider Demographics
NPI:1366572570
Name:PETE AND MARIETTA VESTAL PTRS
Entity type:Organization
Organization Name:PETE AND MARIETTA VESTAL PTRS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARIETTA
Authorized Official - Middle Name:TEMPLIN
Authorized Official - Last Name:VESTAL
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:423-639-2002
Mailing Address - Street 1:910 TUSCULUM BLVD STE 2
Mailing Address - Street 2:
Mailing Address - City:GREENEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37745-4004
Mailing Address - Country:US
Mailing Address - Phone:423-639-2002
Mailing Address - Fax:423-638-4522
Practice Address - Street 1:910 TUSCULUM BLVD STE 2
Practice Address - Street 2:
Practice Address - City:GREENEVILLE
Practice Address - State:TN
Practice Address - Zip Code:37745-4004
Practice Address - Country:US
Practice Address - Phone:423-639-2002
Practice Address - Fax:423-638-4522
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-06
Last Update Date:2014-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNOD0000000490152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3517736Medicaid
TN3593480Medicaid
TN3517736Medicare ID - Type Unspecified
TN3593480Medicare ID - Type Unspecified
TN3517736Medicaid
TN3593480Medicaid