1629195797 NPI number — KNOXVILLE EYE CENTER LLC

Table of content: (NPI 1629195797)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629195797 NPI number — KNOXVILLE EYE CENTER LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KNOXVILLE EYE CENTER 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:
Provider Other Organization Name Type Code:
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:
1629195797
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/07/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
200 FORT SANDERS WEST BLVD STE 101
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KNOXVILLE
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37922-3358
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
865-694-2021
Provider Business Mailing Address Fax Number:
865-694-8234

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
200 FORT SANDERS WEST BLVD
Provider Second Line Business Practice Location Address:
STE 101
Provider Business Practice Location Address City Name:
KNOXVILLE
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37922-3357
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
865-694-2021
Provider Business Practice Location Address Fax Number:
865-694-8234
Provider Enumeration Date:
03/23/2007

Additional Information

Authorized Official

Authorized Official Last Name:
PRICE
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
E
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
865-694-2021

Provider Taxonomy Codes

  • Taxonomy code: 207W00000X , with the licence number:  MD022058 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 180037897 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 3073686 . This is a "BLUECROSS" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".




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