Provider Demographics
NPI:1043563935
Name:MIDSOUTH VISION CENTER
Entity Type:Organization
Organization Name:MIDSOUTH VISION CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER/OPTICIAN
Authorized Official - Prefix:
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:BLAICHER
Authorized Official - Suffix:
Authorized Official - Credentials:OPTICIAN
Authorized Official - Phone:901-373-4207
Mailing Address - Street 1:3314 POPLAR AVE SUITE #1
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38111
Mailing Address - Country:US
Mailing Address - Phone:901-324-3189
Mailing Address - Fax:901-324-2851
Practice Address - Street 1:3314 POPLAR AVE STE#1
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38111
Practice Address - Country:US
Practice Address - Phone:901-324-3189
Practice Address - Fax:901-324-2851
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-17
Last Update Date:2012-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNTN611152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN100197Medicaid
TN100197Medicaid