Healthcare Provider Details

I. General information

NPI: 1720012701
Provider Name (Legal Business Name): JOHNSON CITY EYE SURGERY CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/10/2006
Last Update Date: 10/31/2023
Certification Date: 10/31/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 MED TECH PKWY SUITE 2
JOHNSON CITY TN
37604-4004
US

IV. Provider business mailing address

110 MED TECH PKWY SUITE 2
JOHNSON CITY TN
37604-4004
US

V. Phone/Fax

Practice location:
  • Phone: 423-722-0371
  • Fax: 423-722-0365
Mailing address:
  • Phone: 423-722-0371
  • Fax: 423-722-0365

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QS0132X
TaxonomyOphthalmologic Surgery Clinic/Center
License Number0000000145
License Number StateTN

VIII. Authorized Official

Name: CONNIE S STUFFLESTREET
Title or Position: COMPLIANCE OFFICER
Credential:
Phone: 423-722-0340