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General NPI Number Information
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NPI Number | 1750622874
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Entity Type | Organization
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Legal Business Name | COLLIERVILLE EYECARE PLLC
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Dates
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Enumeration Date | 03/14/2013
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Last Update Date | 03/14/2013
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Provider Practice Location Address
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Address Line | 472 W POPLAR AVE
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City | COLLIERVILLE
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State | TN
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Zip | 38017-2538
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Country | US
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Telephone | 901-219-5040
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Fax |
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Provider Business Mailing Address
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Address Line | 472 W POPLAR AVE
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City | COLLIERVILLE
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State | TN
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Zip | 38017-2538
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Country | US
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Telephone | 901-219-5040
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Fax |
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Authorized Official
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Title or Position | MEMBER
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Name | DR. PAUL MORMON
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Credential | OD
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Telephone | 901-219-5040
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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 | 2254
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License Number State | TN
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