Provider Demographics
NPI:1659559490
Name:EAST MEMPHIS OPTOMETRY PROFESSIONAL ASSOCIATION
Entity Type:Organization
Organization Name:EAST MEMPHIS OPTOMETRY PROFESSIONAL ASSOCIATION
Other - Org Name:LANDON J WALLACE OD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LANDON
Authorized Official - Middle Name:J
Authorized Official - Last Name:WALLACE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:901-683-4529
Mailing Address - Street 1:5118 PARK AVE
Mailing Address - Street 2:SUITE101
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38117-5720
Mailing Address - Country:US
Mailing Address - Phone:901-683-4529
Mailing Address - Fax:901-767-4404
Practice Address - Street 1:5118 PARK AVE
Practice Address - Street 2:SUITE101
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38117
Practice Address - Country:US
Practice Address - Phone:901-683-4529
Practice Address - Fax:901-767-4404
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-04
Last Update Date:2018-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1639481906OtherNPI
TN0828580001Medicare NSC