Healthcare Provider Details

I. General information

NPI: 1376793653
Provider Name (Legal Business Name): THE EYE DOCTOR LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/24/2008
Last Update Date: 12/02/2020
Certification Date: 12/02/2020
Deactivation Date: 11/18/2020
Reactivation Date: 12/02/2020

III. Provider practice location address

1142 MOSBY RD
MEMPHIS TN
38116
US

IV. Provider business mailing address

1142 MOSBY RD
MEMPHIS TN
38116
US

V. Phone/Fax

Practice location:
  • Phone: 901-346-4733
  • Fax: 901-346-4734
Mailing address:
  • Phone: 901-346-4733
  • Fax: 901-346-4734

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: CLINT PIKE
Title or Position: CEO/PRESIDENT
Credential:
Phone: 901-346-4733