=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144498098
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DANA A. GRIST, O.D.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/13/2008
-----------------------------------------------------
Last Update Date | 12/03/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1207 N ROAN ST
-----------------------------------------------------
City | JOHNSON CITY
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37601-3974
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 423-928-1010
-----------------------------------------------------
Fax | 423-928-9090
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1207 N ROAN ST
-----------------------------------------------------
City | JOHNSON CITY
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37601-3974
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 423-928-1010
-----------------------------------------------------
Fax | 423-928-9090
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. DANA ALAN GRIST
-----------------------------------------------------
Credential | O.D.
-----------------------------------------------------
Telephone | 423-928-1010
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | ODT 675
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------