Healthcare Provider Details

I. General information

NPI: 1184465866
Provider Name (Legal Business Name): CALLIE ROOT OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/05/2024
Last Update Date: 06/05/2024
Certification Date: 06/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 MED TECH PKWY STE 1
JOHNSON CITY TN
37604-4004
US

IV. Provider business mailing address

259 SOUTHWOOD DR
KINGSPORT TN
37664-5254
US

V. Phone/Fax

Practice location:
  • Phone: 423-929-2111
  • Fax:
Mailing address:
  • Phone: 423-579-0560
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number3891
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: