Provider Demographics
NPI:1679044044
Name:STANFORD VISION CLINIC LLC
Entity Type:Organization
Organization Name:STANFORD VISION CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MEGAN
Authorized Official - Middle Name:ROEBUCK
Authorized Official - Last Name:STANFORD
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:901-647-0988
Mailing Address - Street 1:306 N COMMERCE ST
Mailing Address - Street 2:
Mailing Address - City:RIPLEY
Mailing Address - State:MS
Mailing Address - Zip Code:38663-1721
Mailing Address - Country:US
Mailing Address - Phone:662-837-7822
Mailing Address - Fax:
Practice Address - Street 1:306 N COMMERCE ST
Practice Address - Street 2:
Practice Address - City:RIPLEY
Practice Address - State:MS
Practice Address - Zip Code:38663-1721
Practice Address - Country:US
Practice Address - Phone:662-837-7822
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-12-11
Last Update Date:2018-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center