Healthcare Provider Details

I. General information

NPI: 1982696498
Provider Name (Legal Business Name): MICHELLE MORRIS HARRISON OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MICHELLE HARRISON OD

II. Dates (important events)

Enumeration Date: 08/19/2005
Last Update Date: 10/05/2022
Certification Date: 10/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

264 HIGHWAY 641 N
CAMDEN TN
38320-1329
US

IV. Provider business mailing address

111 E 4TH ST STE 440
ALTON IL
62002-6241
US

V. Phone/Fax

Practice location:
  • Phone: 731-584-7942
  • Fax: 731-584-7965
Mailing address:
  • Phone: 618-462-9818
  • Fax: 314-741-4947

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOD0000001677
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: