Healthcare Provider Details

I. General information

NPI: 1992431118
Provider Name (Legal Business Name): BOLT EYE GROUP - JOHNSON CITY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/29/2022
Last Update Date: 12/13/2022
Certification Date: 10/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1207 N ROAN ST, SUITE 200
JOHNSON CITY TN
37601
US

IV. Provider business mailing address

4180 OLD MILTON PARKWAY
ALPHARETTA GA
30005
US

V. Phone/Fax

Practice location:
  • Phone: 423-928-1010
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State

VIII. Authorized Official

Name: BARBARA WILLIAMS
Title or Position: BILLING SPECIALIST
Credential:
Phone: 770-776-9000