Healthcare Provider Details

I. General information

NPI: 1205459377
Provider Name (Legal Business Name): ELICK JAN COMBS III OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/25/2020
Last Update Date: 12/07/2022
Certification Date: 12/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

221 E EMORY RD STE 103
POWELL TN
37849-4061
US

IV. Provider business mailing address

1124 E WEISGARBER RD STE 100
KNOXVILLE TN
37909-2686
US

V. Phone/Fax

Practice location:
  • Phone: 865-584-0905
  • Fax: 865-584-3892
Mailing address:
  • Phone: 865-584-0905
  • Fax: 865-584-3892

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number3594
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: