Healthcare Provider Details

I. General information

NPI: 1689221970
Provider Name (Legal Business Name): EYE CENTERS OF TENNESSEE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/21/2019
Last Update Date: 10/21/2020
Certification Date: 10/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

305 N SPRING ST
SPARTA TN
38583-1300
US

IV. Provider business mailing address

15 IRIS LN
CROSSVILLE TN
38555-7528
US

V. Phone/Fax

Practice location:
  • Phone: 931-836-2424
  • Fax: 931-836-1314
Mailing address:
  • Phone: 931-456-2728
  • Fax: 931-456-5446

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number
License Number State

VIII. Authorized Official

Name: ERIK BERGVIN
Title or Position: COO
Credential:
Phone: 931-456-2728