Southern College of Optometry
Organization Active NPI Optometrist · Memphis, TN
NPI 1851384986 · NPPES record last updated Jul 19, 2013
Key facts
- NPI
- 1851384986
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Optometrist 152W00000X
- Legal business name
- SOUTHERN COLLEGE OF OPTOMETRY
- Practice address
- 1225 Madison Ave
Memphis, TN 38104-2211 - Phone
- (901) 722-3250
- Fax
- (901) 722-3347
- NPI assigned
- Aug 24, 2005
- Organization subpart
- No
Authorized official
- Name
- James E Venable, OD
- Title
- Vice President of Clinical Op
- Phone
- (901) 722-3324
Subparts reporting this organization as parent 1
Corporate family (same tax ID) 1
Practitioners 114
-
Mary Bartuccio Valentino, O.D.
-
Marie I. Bodack, O.D.
-
John B Campbell, OD
-
Patricia Cisarik, O.D.
-
Janette D Dumas, OD
-
Jason D Duncan, OD
-
Lindsay M Elkins, OD
-
Michael Scott Ensor, O.D.
-
Patrick Fiddler, OD
-
Daniel Gunn Fuller, O.D.
-
Kristina Marie Haworth, O.D.
-
Cynthia Gale Heard, O.D.
-
Mary Hoang, O.D.
-
Stephanie L Johnson, O.D.
-
Laurel Kelley, OD
-
Aaron M Kerr, OD
-
Tyler Kitzman, O.D.
-
Abigail Klick, OD
-
Brian Knight, O.D.
Laboratory certificates & supplier records
CLIA laboratory certificates
| CLIA number | Laboratory | Certificate | Expires |
|---|---|---|---|
| 44D0313844 | Southern College of Optometry | Certificate of waiver | Jul 8, 2027 |
Medicare medical equipment & supply locations
| Supplier | Supplies | Medicare assignment |
|---|---|---|
| Southern College of Optometry |
Prosthetic Lenses: Conventional Eyeglasses|Prosthetic Lenses: Conventional Contact Lenses|Prosthetic Lenses: Prosthetics Cataract Lenses | Accepts assignment |
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled (2 enrollments) in TN
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20040226000558 | TN | Part B Supplier - Clinic/Group Practice | 4587550454 |
Receives reassigned benefits from 95 practitioners Practice locations: Memphis, TN |
| O20100930038976 | TN | DME Supplier - Physician - Optometrist | 4587550454 | Practice locations: Memphis, TN |
National Provider Directory
- Tax ID family
- So College of Optom-Disp
Locations
4402 Medical Center Dr
Ste 402
Fayetteville, NY 13066
Phone (315) 663-0005
212 Rawlins Service Ct
Ste 201
Memphis, TN 38152
1350 Concourse Ave
Ste 201
Memphis, TN 38104
1225 Madison Ave
Memphis, TN 38104
Phone (901) 722-3250
1350 Concourse Ave
Memphis, TN 38104
Phone (901) 272-0003
212 Rawlins Service Ct
Rm 201
Memphis, TN 38152
1245 Madison Ave
Memphis, TN 38104
Phone (901) 722-3250
1350 Concourse Ave
Ste 264
Memphis, TN 38104
Phone (901) 252-3670
212 Rawlins Serve Ct
Ste 201
Memphis, TN 38152
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Optometrist |
152W00000X | Yes |
Addresses
Primary practice location
1225 Madison Ave
Memphis, TN 38104-2211
Mailing address
1245 Madison Ave
Memphis, TN 38104-2211
Phone (901) 722-3250
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 3517680 | Medicaid | TN |
Other providers in Memphis, TN
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Jul 19, 2013. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- Medicare Care Compare provider data (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.