=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902144256
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FAMILY EYECARE CENTER OF JOHNSON CITY, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/22/2013
-----------------------------------------------------
Last Update Date | 05/03/2013
-----------------------------------------------------
=====================================================
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 A. GRIST
-----------------------------------------------------
Credential | O.D.
-----------------------------------------------------
Telephone | 423-928-1010
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152WV0400X
-----------------------------------------------------
Taxonomy Name | Vision Therapy Optometrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 152WC0802X
-----------------------------------------------------
Taxonomy Name | Corneal and Contact Management Optometrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------