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General NPI Number Information
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NPI Number | 1629477831
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Entity Type | Organization
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Legal Business Name | ANTIOCH EYE CARE CENTER, PHYSICIAN & SURGEON, PLLC
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Dates
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Enumeration Date | 08/14/2014
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Last Update Date | 05/29/2022
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Provider Practice Location Address
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Address Line | 522 BELL RD
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City | ANTIOCH
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State | TN
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Zip | 37013-2002
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Country | US
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Telephone | 615-361-7266
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Fax |
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Provider Business Mailing Address
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Address Line | 554 BELL RD
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City | ANTIOCH
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State | TN
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Zip | 37013-2002
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Country | US
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Telephone | 615-361-7266
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Fax |
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Authorized Official
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Title or Position | OPHTHALMOLOGIST
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Name | BENYAMIN Y EBRAHIM
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Credential | MD
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Telephone | 908-265-2832
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 207W00000X
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Taxonomy Name | Ophthalmology Physician
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License Number | 49780
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License Number State | TN
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