Healthcare Provider Details

I. General information

NPI: 1720161771
Provider Name (Legal Business Name): EYE CARE SURGERY CENTER OF OLIVE BRANCH,LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/23/2006
Last Update Date: 07/25/2022
Certification Date: 07/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6947 CRUMPLER BLVD SUITE 105
OLIVE BRANCH MS
38654-1922
US

IV. Provider business mailing address

825 RIDGE LAKE BLVD
MEMPHIS TN
38120-9411
US

V. Phone/Fax

Practice location:
  • Phone: 662-893-3305
  • Fax: 662-893-3306
Mailing address:
  • Phone: 901-685-2200
  • Fax: 901-255-5631

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. SUBBA R. GOLLAMUDI
Title or Position: MEDICAL DIRECTOR
Credential: M.D.
Phone: 901-685-2200