Provider Demographics
NPI:1497951826
Name:KINGSPORT TN OPHTHALMOLOGY ASC LLC
Entity Type:Organization
Organization Name:KINGSPORT TN OPHTHALMOLOGY ASC LLC
Other - Org Name:REGIONAL EYE SURGERY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:PHILLIP
Authorized Official - Middle Name:
Authorized Official - Last Name:CLENDENIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-665-1283
Mailing Address - Street 1:1A BURTON HILLS BLVD
Mailing Address - Street 2:ATTN: L&C
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37215-6103
Mailing Address - Country:US
Mailing Address - Phone:423-247-2022
Mailing Address - Fax:423-247-2027
Practice Address - Street 1:999 EXECUTIVE PARK BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-4632
Practice Address - Country:US
Practice Address - Phone:423-247-2022
Practice Address - Fax:423-247-2027
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-22
Last Update Date:2023-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
3723239Medicare PIN
3629747Medicare UPIN
3632262Medicare UPIN