1205930666 NPI number — ATLANTA EYE CENTER, LLC

Table of content: (NPI 1205930666)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205930666 NPI number — ATLANTA EYE CENTER, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ATLANTA EYE CENTER, 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:
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:
1205930666
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:
4717 CAMBRIDGE TRCE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DUNWOODY
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30338-5252
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
678-656-6305
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1801 HOWELL MILL RD
Provider Second Line Business Practice Location Address:
WAL-MART VISION CENTER #3775
Provider Business Practice Location Address City Name:
ATLANTA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30318
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
404-352-3414
Provider Business Practice Location Address Fax Number:
404-352-3416
Provider Enumeration Date:
09/07/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
RAHARJA
Authorized Official First Name:
KIM
Authorized Official Middle Name:
C
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
678-656-6305

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  OPT2319 , 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)