Provider Demographics
NPI:1851384986
Name:SOUTHERN COLLEGE OF OPTOMETRY
Entity Type:Organization
Organization Name:SOUTHERN COLLEGE OF OPTOMETRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT OF CLINICAL OP
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:E
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:901-722-3347
Practice Address - Street 1:1225 MADISON AVE
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38104-2211
Practice Address - Country:US
Practice Address - Phone:901-722-3250
Practice Address - Fax:901-722-3347
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-24
Last Update Date:2013-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3517680Medicaid
TN3517680Medicare PIN
TN3517680Medicaid