Provider Demographics
NPI:1386879716
Name:OLD STAGE EYE CARE
Entity type:Organization
Organization Name:OLD STAGE EYE CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:KEVIN
Authorized Official - Last Name:CLEMENT
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:423-639-8856
Mailing Address - Street 1:15 OLD STAGE RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:GREENEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37745-3117
Mailing Address - Country:US
Mailing Address - Phone:423-639-8856
Mailing Address - Fax:423-639-8227
Practice Address - Street 1:15 OLD STAGE RD
Practice Address - Street 2:SUITE A
Practice Address - City:GREENEVILLE
Practice Address - State:TN
Practice Address - Zip Code:37745-3117
Practice Address - Country:US
Practice Address - Phone:423-639-8856
Practice Address - Fax:423-639-8227
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-29
Last Update Date:2009-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNODT 1457152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN6167110001Medicare NSC