Healthcare Provider Details

I. General information

NPI: 1164095758
Provider Name (Legal Business Name): ZEKE PARKER GRISSOM OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2021
Last Update Date: 08/03/2021
Certification Date: 08/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

915 COLLOREDO BLVD
SHELBYVILLE TN
37160-2780
US

IV. Provider business mailing address

515 GREGORY MILL RD
SHELBYVILLE TN
37160-5565
US

V. Phone/Fax

Practice location:
  • Phone: 931-684-2197
  • Fax: 931-229-1112
Mailing address:
  • Phone: 931-703-9954
  • Fax: 931-229-1112

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number3676
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: