Healthcare Provider Details

I. General information

NPI: 1477874501
Provider Name (Legal Business Name): REGINA J. ELKINS, O.D.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/11/2010
Last Update Date: 06/10/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 1/2 E PUBLIC SQ
CENTERVILLE TN
37033-1601
US

IV. Provider business mailing address

205 1/2 E PUBLIC SQ
CENTERVILLE TN
37033-1601
US

V. Phone/Fax

Practice location:
  • Phone: 931-729-2190
  • Fax: 931-729-2805
Mailing address:
  • Phone: 931-729-2190
  • Fax: 931-729-2805

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOD0000000807
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOD0000001419
License Number StateTN

VIII. Authorized Official

Name: REGINA J ELKINS
Title or Position: OWNER
Credential: OD
Phone: 931-729-2190