Provider Demographics
NPI:1124491246
Name:COREY GLENN PERSONS
Entity type:Organization
Organization Name:COREY GLENN PERSONS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:COREY
Authorized Official - Middle Name:GLENN
Authorized Official - Last Name:PERSONS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:731-256-7911
Mailing Address - Street 1:1239 VANN DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38305-4918
Mailing Address - Country:US
Mailing Address - Phone:731-256-7911
Mailing Address - Fax:731-664-5243
Practice Address - Street 1:1239 VANN DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38305-4918
Practice Address - Country:US
Practice Address - Phone:731-256-7911
Practice Address - Fax:731-664-5243
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-11
Last Update Date:2021-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1779152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ020091Medicaid
TNQ020087Medicaid