=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255860383
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EYE SURGERY CENTER OF KNOXVILLE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/12/2017
-----------------------------------------------------
Last Update Date | 08/21/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7739 DANNAHER DRIVE
-----------------------------------------------------
City | POWELL
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37849
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 865-339-4200
-----------------------------------------------------
Fax | 865-362-5532
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 448 N CEDAR BLUFF RD STE 255
-----------------------------------------------------
City | KNOXVILLE
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37923-3612
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 865-339-4200
-----------------------------------------------------
Fax | 865-362-5532
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF OPERATING OFFICER
-----------------------------------------------------
Name | MR. STEPHEN H RUDOLPH SR.
-----------------------------------------------------
Credential | CPA
-----------------------------------------------------
Telephone | 865-339-4200
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA1903X
-----------------------------------------------------
Taxonomy Name | Ambulatory Surgical Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------