Basic Information
| Provider Information | |||||||||
| NPI: | 1043643398 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHERN EYE CONSULTANTS, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 503 FURYS FERRY RD | ||||||||
| Address2: | |||||||||
| City: | MARTINEZ | ||||||||
| State: | GA | ||||||||
| PostalCode: | 309079059 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7068608899 | ||||||||
| FaxNumber: | 7068637822 | ||||||||
| Practice Location | |||||||||
| Address1: | 503 FURYS FERRY RD | ||||||||
| Address2: | |||||||||
| City: | MARTINEZ | ||||||||
| State: | GA | ||||||||
| PostalCode: | 309079059 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7068608899 | ||||||||
| FaxNumber: | 7068637822 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2013 | ||||||||
| LastUpdateDate: | 08/15/2013 | ||||||||
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| AuthorizedOfficialLastName: | MORGAN | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7068608899 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SOUTHERN EYE CONSULTANTS, LLC | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | O.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | OPT002458 | GA | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | DG2458 | 05 | SC | MEDICAID | 724809439B | 05 | GA | MEDICAID |