Healthcare Provider Details

I. General information

NPI: 1639162688
Provider Name (Legal Business Name): BRENTA MEDLEY O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/25/2005
Last Update Date: 01/09/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

499 E. WINCHESTER BLVD SUITE 101
COLLIERVILLE TN
38017-4054
US

IV. Provider business mailing address

499 E. WINCHESTER BLVD SUITE 101
COLLIERVILLE TN
38017-4054
US

V. Phone/Fax

Practice location:
  • Phone: 901-850-2366
  • Fax: 901-850-2367
Mailing address:
  • Phone: 901-850-2366
  • Fax: 901-850-2367

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1748
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: