Provider Demographics
NPI:1215675541
Name:WILSON COUNTY EYE ASSOCIATES, LLC
Entity type:Organization
Organization Name:WILSON COUNTY EYE ASSOCIATES, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JEREMY
Authorized Official - Middle Name:C
Authorized Official - Last Name:SCOGGINS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:615-491-4245
Mailing Address - Street 1:327 WINDHAVEN BAY
Mailing Address - Street 2:
Mailing Address - City:MT JULIET
Mailing Address - State:TN
Mailing Address - Zip Code:37122-6912
Mailing Address - Country:US
Mailing Address - Phone:615-491-4245
Mailing Address - Fax:615-832-4321
Practice Address - Street 1:615 S CUMBERLAND ST
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:TN
Practice Address - Zip Code:37087-5107
Practice Address - Country:US
Practice Address - Phone:615-547-9670
Practice Address - Fax:615-832-4321
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WILSON COUNTY EYE ASSOCIATES, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-05-25
Last Update Date:2022-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3944398Medicaid