1003208711 NPI number — OPTIQUE PCM

Table of content: (NPI 1003208711)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003208711 NPI number — OPTIQUE PCM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OPTIQUE PCM
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:
6
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:
1003208711
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/28/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1244 W PACES FERRY RD NW
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30327-2306
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
404-875-2766
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
650 NORTH AVE NE
Provider Second Line Business Practice Location Address:
SUITE S103
Provider Business Practice Location Address City Name:
ATLANTA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30308-2705
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
404-875-2766
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/04/2015

Additional Information

Authorized Official

Authorized Official Last Name:
COHEN
Authorized Official First Name:
GAVIN
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
404-405-8539

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  1768 , 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: 1760512040 . This is a "NPI" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com