Healthcare Provider Details

I. General information

NPI: 1154055069
Provider Name (Legal Business Name): SARAH JORDAN COLLINS SHELL O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MRS. SARAH JORDAN COLLINS

II. Dates (important events)

Enumeration Date: 07/15/2022
Last Update Date: 07/15/2022
Certification Date: 07/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

135 SOUTH BELLS STREET
ALAMO TN
38001
US

IV. Provider business mailing address

135 SOUTH BELLS STREET
ALAMO TN
38001
US

V. Phone/Fax

Practice location:
  • Phone: 731-696-4004
  • Fax: 731-696-4009
Mailing address:
  • Phone: 731-696-4004
  • Fax: 731-696-4009

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number3736
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: