Provider Demographics
NPI:1689812125
Name:SENIOR EYE CARE OF JOHNSON CITY LLC
Entity Type:Organization
Organization Name:SENIOR EYE CARE OF JOHNSON CITY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:E
Authorized Official - Last Name:COX
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:423-928-0975
Mailing Address - Street 1:PO BOX 7756
Mailing Address - Street 2:
Mailing Address - City:ROCKY MOUNT
Mailing Address - State:NC
Mailing Address - Zip Code:27804-0756
Mailing Address - Country:US
Mailing Address - Phone:252-985-1371
Mailing Address - Fax:
Practice Address - Street 1:7 HORSESHOE BND
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-7185
Practice Address - Country:US
Practice Address - Phone:423-928-0975
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-21
Last Update Date:2009-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
U35837Medicare UPIN