Provider Demographics
NPI:1376793653
Name:THE EYE DOCTOR LLC
Entity Type:Organization
Organization Name:THE EYE DOCTOR LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CLINT
Authorized Official - Middle Name:
Authorized Official - Last Name:PIKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:901-346-4733
Mailing Address - Street 1:1142 MOSBY RD
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38116
Mailing Address - Country:US
Mailing Address - Phone:901-346-4733
Mailing Address - Fax:901-346-4734
Practice Address - Street 1:1142 MOSBY RD
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38116
Practice Address - Country:US
Practice Address - Phone:901-346-4733
Practice Address - Fax:901-346-4734
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-24
Last Update Date:2020-12-02
Deactivation Date:2020-11-18
Deactivation Code:
Reactivation Date:2020-12-02
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3289016Medicare PIN
TN6442120001Medicare NSC