Healthcare Provider Details

I. General information

NPI: 1992103253
Provider Name (Legal Business Name): NORTHWEST TENNESSEE EYE CLINIC, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/18/2014
Last Update Date: 02/05/2024
Certification Date: 02/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 HIGHWAY 431
MARTIN TN
38237-8264
US

IV. Provider business mailing address

111 HIGHWAY 431
MARTIN TN
38237-8264
US

V. Phone/Fax

Practice location:
  • Phone: 731-587-2022
  • Fax:
Mailing address:
  • Phone: 731-587-2022
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberTN1767
License Number StateTN

VIII. Authorized Official

Name: FRANCES DICKSON BYNUM
Title or Position: OWNER
Credential:
Phone: 731-587-2022