1295721082 NPI number — 1 HOUR OPTICAL P C

Table of content: (NPI 1295721082)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295721082 NPI number — 1 HOUR OPTICAL P C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
1 HOUR OPTICAL P C
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1295721082
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
217 BOBBY JONES EXPY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
AUGUSTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30907-5255
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
706-860-1171
Provider Business Mailing Address Fax Number:
706-860-1841

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
217 BOBBY JONES EXPY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
AUGUSTA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30907-5255
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
706-860-1171
Provider Business Practice Location Address Fax Number:
706-860-1841
Provider Enumeration Date:
09/27/2005

Additional Information

Authorized Official

Authorized Official Last Name:
CROOK
Authorized Official First Name:
GARY
Authorized Official Middle Name:
G
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
706-860-1171

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  GA717 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: DPG717 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 5132270001 . This is a "DMERC" identifier . This identifiers is of the category "OTHER".
  • Identifier: 52540781004 . This is a "BCBS" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: DAG983 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 5055266711 . This is a "TRICARE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: GA0717 . This is a "EYEMED" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".




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