1952569279 NPI number — NORTH GEORGIA VISION CENTER INC

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1952569279 NPI number — NORTH GEORGIA VISION CENTER INC

Employer Identification Number (EIN):

Provider Organization Name:

NORTH GEORGIA VISION CENTER INC

Provider Last Name:

Provider First Name:

Provider Middle Name:

Provider Name Prefix Text:

Provider Name Suffix Text:

Provider Credential Text:

Provider Gender Code:

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:

1952569279

Entity Type Code:

Organization

Replacement NPI:

Last Update Date:

06/08/2021

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider First Line Business Mailing Address:

8390 N HIGHWAY 27

Provider Second Line Business Mailing Address:

Provider Business Mailing Address City Name:

ROCK SPRING

Provider Business Mailing Address State Name:

GA

Provider Business Mailing Address Postal Code:

30739-2103

Provider Business Mailing Address Country Code:

US

Provider Business Mailing Address Telephone Number:

706-375-1720

Provider Business Mailing Address Fax Number:

706-375-1729

Provider First Line Business Practice Location Address:

8390 N HIGHWAY 27

Provider Second Line Business Practice Location Address:

Provider Business Practice Location Address City Name:

ROCK SPRING

Provider Business Practice Location Address State Name:

GA

Provider Business Practice Location Address Postal Code:

30739-2103

Provider Business Practice Location Address Country Code:

US

Provider Business Practice Location Address Telephone Number:

706-375-1720

Provider Business Practice Location Address Fax Number:

706-375-1729

Provider Enumeration Date:

05/23/2008

Authorized Official Last Name:

CLARK

Authorized Official First Name:

STEPHEN

Authorized Official Middle Name:

BRENT

Authorized Official Title or Position:

OPTOMETRIST OWNER

Authorized Official Telephone Number:

706-375-1720

• Taxonomy code: 152W00000X , with the licence number:  OD0000002478 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 152W00000X , with the licence number: OPT002352 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

• Identifier: 205370293 . This is a "NVA" identifier . This identifiers is of the category "OTHER".
• Identifier: 41ZCGGN . This is a "MEDICARE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
• Identifier: 59526 . This is a "DAVIS VISION" identifier . This identifiers is of the category "OTHER".
• Identifier: 911517 . This is a "EYE MED" identifier . This identifiers is of the category "OTHER".
• Identifier: 4115539 . This is a "BCBS" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
• Identifier: 45460 . This is a "SPECTERA" identifier . This identifiers is of the category "OTHER".
• Identifier: 101846 . This is a "AVESIS" identifier . This identifiers is of the category "OTHER".
• Identifier: 33901 . This is a "OPTI CARE" identifier . This identifiers is of the category "OTHER".
• Identifier: 41ZCGGN . This is a "MEDICARE GA" identifier . This identifiers is of the category "OTHER".
• Identifier: 194699738A . This is a "MEDICARE GA" identifier . This identifiers is of the category "OTHER".
• Identifier: 927618 . This is a "BLOCK VISION LOCATION NUMBER 114419" identifier . This identifiers is of the category "OTHER".
• Identifier: 194699738A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".