Healthcare Provider Details

I. General information

NPI: 1457562266
Provider Name (Legal Business Name): PEARLE VISION CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/24/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6115 HICKORY RIDGE MALL
MEMPHIS TN
38115-8806
US

IV. Provider business mailing address

6115 HICKORY RIDGE MALL
MEMPHIS TN
38115-8806
US

V. Phone/Fax

Practice location:
  • Phone: 901-362-1496
  • Fax:
Mailing address:
  • Phone: 901-362-1496
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code305R00000X
TaxonomyPreferred Provider Organization
License Number482
License Number StateTN

VIII. Authorized Official

Name: TINA FLY
Title or Position: OWNER LICENSED OPTICIAN
Credential:
Phone: 901-362-1496