Healthcare Provider Details

I. General information

NPI: 1114179587
Provider Name (Legal Business Name): SKYLINE EYE CLINIC, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/16/2008
Last Update Date: 10/16/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

138 HOUSTON AVE
SELMER TN
38375-2127
US

IV. Provider business mailing address

138 HOUSTON AVE
SELMER TN
38375-2127
US

V. Phone/Fax

Practice location:
  • Phone: 731-645-7255
  • Fax:
Mailing address:
  • Phone: 731-645-7255
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number457
License Number StateTN

VIII. Authorized Official

Name: RAYMOND J KEE
Title or Position: ADMINISTRATOR/CEO
Credential:
Phone: 731-424-2414