Provider Demographics
NPI:1053385856
Name:JACKSON OPHTHALMOLOGY ASC LLC
Entity type:Organization
Organization Name:JACKSON OPHTHALMOLOGY ASC LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MARKET PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SEAN
Authorized Official - Middle Name:
Authorized Official - Last Name:NEEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:731-661-6343
Mailing Address - Street 1:207 STONEBRIDGE BLVD
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38305-2040
Mailing Address - Country:US
Mailing Address - Phone:731-661-6340
Mailing Address - Fax:731-661-6363
Practice Address - Street 1:207 STONEBRIDGE BLVD
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38305-2040
Practice Address - Country:US
Practice Address - Phone:731-661-6340
Practice Address - Fax:731-661-6363
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-16
Last Update Date:2024-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000000075261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3288377Medicare PIN