1497951826 NPI number — KINGSPORT TN OPHTHALMOLOGY ASC LLC

Table of content: (NPI 1497951826)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497951826 NPI number — KINGSPORT TN OPHTHALMOLOGY ASC LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KINGSPORT TN OPHTHALMOLOGY ASC LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
REGIONAL EYE SURGERY CENTER
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1497951826
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1A BURTON HILLS BLVD
Provider Second Line Business Mailing Address:
ATTN: L&C
Provider Business Mailing Address City Name:
NASHVILLE
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37215-6103
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
423-247-2022
Provider Business Mailing Address Fax Number:
423-247-2027

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
999 EXECUTIVE PARK BLVD
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
KINGSPORT
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37660-4632
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-247-2022
Provider Business Practice Location Address Fax Number:
423-247-2027
Provider Enumeration Date:
06/22/2007

Additional Information

Authorized Official

Authorized Official Last Name:
CLENDENIN
Authorized Official First Name:
PHILLIP
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
615-665-1283

Provider Taxonomy Codes

  • Taxonomy code: 367500000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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