=====================================================
General NPI Number Information
=====================================================
NPI Number | 1801075346
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DR. J. SCOTT GENTRY, O.D., P.C,
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/01/2007
-----------------------------------------------------
Last Update Date | 11/01/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 301 MONTGOMERY ST
-----------------------------------------------------
City | JOHNSON CITY
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37604-5629
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 423-926-2642
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 301 MONTGOMERY ST
-----------------------------------------------------
City | JOHNSON CITY
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37604-5629
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 423-926-2642
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO/OWNER
-----------------------------------------------------
Name | DR. JOHN SCOTT GENTRY
-----------------------------------------------------
Credential | O.D.
-----------------------------------------------------
Telephone | 423-926-2642
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | ODT827
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------