Provider Demographics
NPI:1811054232
Name:WEST TENNESSEE EYE ASSOCIATES PC
Entity type:Organization
Organization Name:WEST TENNESSEE EYE ASSOCIATES PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SANDY
Authorized Official - Middle Name:
Authorized Official - Last Name:FISH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:731-664-1994
Mailing Address - Street 1:112 STONEBRIDGE BLVD
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38305-2038
Mailing Address - Country:US
Mailing Address - Phone:731-664-1994
Mailing Address - Fax:731-664-2903
Practice Address - Street 1:112 STONEBRIDGE BLVD
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38305-2038
Practice Address - Country:US
Practice Address - Phone:731-664-1994
Practice Address - Fax:731-664-2903
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNOD1410152W00000X
TNMD38610152WC0802X
TNMD019471152WX0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Not Answered152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact ManagementGroup - Multi-Specialty
Not Answered152WX0102XEye and Vision Services ProvidersOptometristOccupational VisionGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3044467Medicaid
TN3896438Medicaid
TN3598351Medicaid
TN3896438Medicaid
TN3044467Medicaid
TN3598351Medicare ID - Type Unspecified
TN3598351Medicaid
TNI04668Medicare UPIN
TN3896438Medicare ID - Type Unspecified