1871773788 NPI number — WEST GEORGIA OPTICAL, LLC

Table of content: (NPI 1871773788)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871773788 NPI number — WEST GEORGIA OPTICAL, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WEST GEORGIA OPTICAL, LLC
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:
WEST GEORGIA OPTICAL, INC
Provider Other Organization Name Type Code:
4
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:
1871773788
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/05/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2616 WARM SPRINGS RD
Provider Second Line Business Mailing Address:
SUITE A
Provider Business Mailing Address City Name:
COLUMBUS
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31904-5323
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
706-323-0149
Provider Business Mailing Address Fax Number:
706-660-9191

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2616 WARM SPRINGS RD
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
COLUMBUS
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31904-5323
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
706-323-0149
Provider Business Practice Location Address Fax Number:
706-660-9191
Provider Enumeration Date:
11/08/2007

Additional Information

Authorized Official

Authorized Official Last Name:
HOLLOWAY
Authorized Official First Name:
MARK
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
706-323-3491

Provider Taxonomy Codes

  • Taxonomy code: 332H00000X , with the licence number:  001254 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 332H00000X , with the licence number: 030005 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 332H00000X , with the licence number: 017594 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 332H00000X , with the licence number: 034249 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 332H00000X , with the licence number: 039057 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 332H00000X , with the licence number: 047418 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 332H00000X , with the licence number: 049643 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 332H00000X , with the licence number: 054799 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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





Copyright © 2007-2024 www.npivalidator.com