1639775588 NPI number — EAST ATHENS FAMILY VISION, LLC

Table of content: (NPI 1639775588)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639775588 NPI number — EAST ATHENS FAMILY VISION, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EAST ATHENS FAMILY VISION, 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:
1639775588
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/17/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
270 HAWTHORNE AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ATHENS
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30606-2881
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
706-850-7101
Provider Business Mailing Address Fax Number:
706-850-7089

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
850 GAINES SCHOOL RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ATHENS
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30605-3132
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
706-850-7101
Provider Business Practice Location Address Fax Number:
706-850-7089
Provider Enumeration Date:
12/07/2020

Additional Information

Authorized Official

Authorized Official Last Name:
SPRINGER
Authorized Official First Name:
RUSSELL
Authorized Official Middle Name:
DOUGLAS
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
706-543-3599

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 003257528A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 00772098A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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