1386612703 NPI number — SISTAR EYECARE ASSOCIATES

Table of content: (NPI 1386612703)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386612703 NPI number — SISTAR EYECARE ASSOCIATES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SISTAR EYECARE ASSOCIATES
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:
1386612703
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/14/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1465
Provider Second Line Business Mailing Address:
545 KNIGHT AVE
Provider Business Mailing Address City Name:
WAYCROSS
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31502-1465
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
912-285-0020
Provider Business Mailing Address Fax Number:
912-285-8222

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
545 KNIGHT AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WAYCROSS
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31501-3354
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
912-285-0020
Provider Business Practice Location Address Fax Number:
912-285-8222
Provider Enumeration Date:
03/10/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
SISTER
Authorized Official First Name:
JAMES
Authorized Official Middle Name:
LEON
Authorized Official Title or Position:
OPTOMETRIST CEO
Authorized Official Telephone Number:
912-285-0020

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  919T , 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: 00204663D , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 52194992 . This is a "BCBS" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".