Healthcare Provider Details

I. General information

NPI: 1497951826
Provider Name (Legal Business Name): KINGSPORT TN OPHTHALMOLOGY ASC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/22/2007
Last Update Date: 09/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

999 EXECUTIVE PARK BLVD SUITE 100
KINGSPORT TN
37660-4632
US

IV. Provider business mailing address

1A BURTON HILLS BLVD ATTN: L&C
NASHVILLE TN
37215-6103
US

V. Phone/Fax

Practice location:
  • Phone: 423-247-2022
  • Fax: 423-247-2027
Mailing address:
  • Phone: 423-247-2022
  • Fax: 423-247-2027

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number
License Number State

VIII. Authorized Official

Name: MR. PHILLIP CLENDENIN
Title or Position: PRESIDENT
Credential:
Phone: 615-665-1283