Healthcare Provider Details

I. General information

NPI: 1598955999
Provider Name (Legal Business Name): JEREMY AND SUMMER ANDERSON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/31/2007
Last Update Date: 09/25/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1911 MCARTHUR ST
MANCHESTER TN
37355-2688
US

IV. Provider business mailing address

1911 MCARTHUR ST
MANCHESTER TN
37355-2688
US

V. Phone/Fax

Practice location:
  • Phone: 931-728-1315
  • Fax: 931-728-1779
Mailing address:
  • Phone: 931-728-1315
  • Fax: 931-728-1779

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. JEREMY W ANDERSON
Title or Position: OWNER
Credential: O.D.
Phone: 931-728-1315