1700244472 NPI number — ALPHA AND OMEGA VISION CENTER

Table of content: (NPI 1700244472)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700244472 NPI number — ALPHA AND OMEGA VISION CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ALPHA AND OMEGA VISION CENTER
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:
INSIGHT FAMILY EYE CARE
Provider Other Organization Name Type Code:
3
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:
1700244472
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/09/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
264 GUSTAV CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NORTH AUGUSTA
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29860-8212
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
803-546-5740
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3836 WASHINGTON RD
Provider Second Line Business Practice Location Address:
SUITE 2
Provider Business Practice Location Address City Name:
MARTINEZ
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30907-5058
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
706-410-2038
Provider Business Practice Location Address Fax Number:
706-608-4080
Provider Enumeration Date:
02/09/2016

Additional Information

Authorized Official

Authorized Official Last Name:
SEWARD-BROWN
Authorized Official First Name:
SHERITA
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
803-546-5740

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  002623 , 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: D16310 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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