1659520542 NPI number — EYE CARE ASSOCIATES OF MIDDLE GA

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659520542 NPI number — EYE CARE ASSOCIATES OF MIDDLE GA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EYE CARE ASSOCIATES OF MIDDLE GA
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:
1659520542
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/16/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
198 S HOUSTON LAKE RD
Provider Second Line Business Mailing Address:
STE B
Provider Business Mailing Address City Name:
WARNER ROBINS
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31088-6473
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
478-971-1500
Provider Business Mailing Address Fax Number:
478-971-2112

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1634 VETERANS BLVD
Provider Second Line Business Practice Location Address:
STE C
Provider Business Practice Location Address City Name:
DUBLIN
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31021-3500
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
478-272-0249
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/16/2008

Additional Information

Authorized Official

Authorized Official Last Name:
CHRISTIE
Authorized Official First Name:
DUDLEY
Authorized Official Middle Name:
B
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
478-971-1500

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  OPT001236 , 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)





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