Healthcare Provider Details

I. General information

NPI: 1376156554
Provider Name (Legal Business Name): MARIAM GIRGES
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/26/2020
Last Update Date: 08/26/2020
Certification Date: 08/26/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

126 E BOCKMAN WAY
SPARTA TN
38583-2036
US

IV. Provider business mailing address

126 E BOCKMAN WAY
SPARTA TN
38583-2036
US

V. Phone/Fax

Practice location:
  • Phone: 931-836-2235
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number3603
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: