1740776517 NPI number — TAKLE EYE SURGERY CENTER LLC

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 1740776517 NPI number — TAKLE EYE SURGERY CENTER LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TAKLE EYE SURGERY 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:
1740776517
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/19/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1075 BANDY PKWY STE 105
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOCUST GROVE
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30248-7036
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-282-3590
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1075 BANDY PKWY
Provider Second Line Business Practice Location Address:
STE 105
Provider Business Practice Location Address City Name:
LOCUST GROVE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30248
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-228-3836
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/05/2018

Additional Information

Authorized Official

Authorized Official Last Name:
TAKLE
Authorized Official First Name:
LEIV
Authorized Official Middle Name:
M
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
770-228-3836

Provider Taxonomy Codes

  • Taxonomy code: 261QA1903X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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