Provider Demographics
NPI:1518309202
Name:SOUTHERN COLLEGE OF OPTOMETRY
Entity Type:Organization
Organization Name:SOUTHERN COLLEGE OF OPTOMETRY
Other - Org Name:UNIVERSITY EYE CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP OF CLINICAL OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:VENABLE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:901-722-3324
Mailing Address - Street 1:1245 MADISON AVE
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38104-2211
Mailing Address - Country:US
Mailing Address - Phone:901-722-3250
Mailing Address - Fax:901-722-3388
Practice Address - Street 1:212 RAWLINS SERVICE CT
Practice Address - Street 2:ROOM 201
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38152-0001
Practice Address - Country:US
Practice Address - Phone:901-722-3250
Practice Address - Fax:901-722-3347
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SOUTHERN COLLEGE OF OPTOMETRY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-07-23
Last Update Date:2021-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1265152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3517680Medicare PIN