Healthcare Provider Details

I. General information

NPI: 1578773263
Provider Name (Legal Business Name): COMPLETE EYE CARE, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/23/2007
Last Update Date: 01/20/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9453 DAYTON PIKE
SODDY DAISY TN
37379-4751
US

IV. Provider business mailing address

9453 DAYTON PIKE
SODDY DAISY TN
37379-4751
US

V. Phone/Fax

Practice location:
  • Phone: 423-332-8222
  • Fax: 423-332-8278
Mailing address:
  • Phone: 423-332-8222
  • Fax: 423-332-8278

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberMD0000028919
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number28919
License Number StateTN

VIII. Authorized Official

Name: JOHN D. BONNER
Title or Position: PRESIDENT
Credential: M.D.
Phone: 423-332-8222