Provider Demographics
NPI:1679607923
Name:WEST TENNESSEE EYE
Entity Type:Organization
Organization Name:WEST TENNESSEE EYE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ANGIE
Authorized Official - Middle Name:
Authorized Official - Last Name:BLACK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:901-872-2020
Mailing Address - Street 1:2070 WHITNEY AVE
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38127-9014
Mailing Address - Country:US
Mailing Address - Phone:901-872-2020
Mailing Address - Fax:901-358-7574
Practice Address - Street 1:1999 HWY 51 SOUTH
Practice Address - Street 2:SUITE B
Practice Address - City:COVINGTON
Practice Address - State:TN
Practice Address - Zip Code:38019
Practice Address - Country:US
Practice Address - Phone:901-872-2020
Practice Address - Fax:901-358-7574
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WEST TENNESSEE EYE, PLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-03-16
Last Update Date:2018-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1797152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3941292Medicare ID - Type UnspecifiedGROUP PRACTICE NUMBER
TN0261030003Medicare NSC