=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659407070
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MABRY EYE CENTER PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/27/2007
-----------------------------------------------------
Last Update Date | 02/07/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1210 PREMIER DR SUITE #110
-----------------------------------------------------
City | CHATTANOOGA
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37421-3747
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 423-385-2020
-----------------------------------------------------
Fax | 423-385-2021
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1210 PREMIER DR SUITE #110
-----------------------------------------------------
City | CHATTANOOGA
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37421-3747
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 423-385-2020
-----------------------------------------------------
Fax | 423-385-2021
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. ELIZABETH D. MABRY
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 423-385-2020
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207W00000X
-----------------------------------------------------
Taxonomy Name | Ophthalmology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------