=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073773958
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DRS. KELLUM & PIKE, PC OPTOMETRISTS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/13/2008
-----------------------------------------------------
Last Update Date | 07/31/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 215 W WATAUGA AVE
-----------------------------------------------------
City | JOHNSON CITY
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37604-5628
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 423-926-0551
-----------------------------------------------------
Fax | 423-926-5251
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 215 W WATAUGA AVE
-----------------------------------------------------
City | JOHNSON CITY
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37604-5628
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DOCTOR OF OPTOMETRY
-----------------------------------------------------
Name | DR. WILLIAM A PIKE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 423-926-0551
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | ODT514
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------