Provider Demographics
NPI:1861728263
Name:JONESBOROUGH EYE CLINIC, PLLC
Entity type:Organization
Organization Name:JONESBOROUGH EYE CLINIC, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:KRISTEN
Authorized Official - Middle Name:BROOKE
Authorized Official - Last Name:PUMPHREY
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:423-753-7760
Mailing Address - Street 1:395 FOREST CIR
Mailing Address - Street 2:UNIT 120
Mailing Address - City:JONESBOROUGH
Mailing Address - State:TN
Mailing Address - Zip Code:37659-1439
Mailing Address - Country:US
Mailing Address - Phone:423-753-7760
Mailing Address - Fax:423-753-7466
Practice Address - Street 1:395 FOREST CIR
Practice Address - Street 2:UNIT 120
Practice Address - City:JONESBOROUGH
Practice Address - State:TN
Practice Address - Zip Code:37659-1439
Practice Address - Country:US
Practice Address - Phone:423-753-7760
Practice Address - Fax:423-753-7466
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-20
Last Update Date:2014-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2691152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact ManagementGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN6363950001OtherDMERC REGION C
TN6363950001OtherDMERC REGION C