Provider Demographics
NPI:1073773958
Name:DRS. KELLUM & PIKE, PC OPTOMETRISTS
Entity Type:Organization
Organization Name:DRS. KELLUM & PIKE, PC OPTOMETRISTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR OF OPTOMETRY
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:A
Authorized Official - Last Name:PIKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-926-0551
Mailing Address - Street 1:215 W WATAUGA AVE
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-5628
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:215 W WATAUGA AVE
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-5628
Practice Address - Country:US
Practice Address - Phone:423-926-0551
Practice Address - Fax:423-926-5251
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-13
Last Update Date:2008-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNODT514152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
0529820001Medicare NSC