Basic Information
| Provider Information | |||||||||
| NPI: | 1306284229 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MEDINA EYE CLINIC PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | P O BOX 865 | ||||||||
| Address2: | |||||||||
| City: | CAMDEN | ||||||||
| State: | TN | ||||||||
| PostalCode: | 383201329 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7315847942 | ||||||||
| FaxNumber: | 7315847965 | ||||||||
| Practice Location | |||||||||
| Address1: | 615 HWY 45 SOUTH | ||||||||
| Address2: | |||||||||
| City: | MEDINA | ||||||||
| State: | TN | ||||||||
| PostalCode: | 383550479 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7315847942 | ||||||||
| FaxNumber: | 7315847965 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/13/2013 | ||||||||
| LastUpdateDate: | 08/27/2020 | ||||||||
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| AuthorizedOfficialLastName: | HARRISON | ||||||||
| AuthorizedOfficialFirstName: | HOLLY | ||||||||
| AuthorizedOfficialMiddleName: | MICHELLE | ||||||||
| AuthorizedOfficialTitleorPosition: | OPTOMETRIST | ||||||||
| AuthorizedOfficialTelephone: | 7315847942 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | O.D. | ||||||||
| NPICertificationDate: | 08/27/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 1677 | TN | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
No ID Information.