Basic Information
| Provider Information | |||||||||
| NPI: | 1689812125 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SENIOR EYE CARE OF JOHNSON CITY LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 7756 | ||||||||
| Address2: | |||||||||
| City: | ROCKY MOUNT | ||||||||
| State: | NC | ||||||||
| PostalCode: | 278040756 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2529851371 | ||||||||
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| Practice Location | |||||||||
| Address1: | 7 HORSESHOE BND | ||||||||
| Address2: | |||||||||
| City: | JOHNSON CITY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376047185 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4239280975 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/21/2009 | ||||||||
| LastUpdateDate: | 01/21/2009 | ||||||||
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| AuthorizedOfficialLastName: | COX | ||||||||
| AuthorizedOfficialFirstName: | SAMUEL | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 4239280975 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | OD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
No ID Information.