Provider Demographics
NPI:1720012701
Name:JOHNSON CITY EYE SURGERY CENTER
Entity Type:Organization
Organization Name:JOHNSON CITY EYE SURGERY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COMPLIANCE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:CONNIE
Authorized Official - Middle Name:S
Authorized Official - Last Name:STUFFLESTREET
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-722-0340
Mailing Address - Street 1:110 MED TECH PKWY
Mailing Address - Street 2:SUITE 2
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-4004
Mailing Address - Country:US
Mailing Address - Phone:423-722-0371
Mailing Address - Fax:423-722-0365
Practice Address - Street 1:110 MED TECH PKWY
Practice Address - Street 2:SUITE 2
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-4004
Practice Address - Country:US
Practice Address - Phone:423-722-0371
Practice Address - Fax:423-722-0365
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-10
Last Update Date:2023-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000000145261QS0132X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS0132XAmbulatory Health Care FacilitiesClinic/CenterOphthalmologic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3288836Medicare ID - Type Unspecified