Provider Demographics
NPI:1902144256
Name:FAMILY EYECARE CENTER OF JOHNSON CITY, PLLC
Entity Type:Organization
Organization Name:FAMILY EYECARE CENTER OF JOHNSON CITY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DANA
Authorized Official - Middle Name:A
Authorized Official - Last Name:GRIST
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:423-928-1010
Mailing Address - Street 1:1207 N ROAN ST
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37601-3974
Mailing Address - Country:US
Mailing Address - Phone:423-928-1010
Mailing Address - Fax:423-928-9090
Practice Address - Street 1:1207 N ROAN ST
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37601-3974
Practice Address - Country:US
Practice Address - Phone:423-928-1010
Practice Address - Fax:423-928-9090
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-22
Last Update Date:2013-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact ManagementGroup - Multi-Specialty
No152WV0400XEye and Vision Services ProvidersOptometristVision TherapyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN103G702480Medicare PIN