Basic Information
| Provider Information | |||||||||
| NPI: | 1053545723 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BAXLEY EYECARE CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 206 MAPLE DR | ||||||||
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| City: | VIDALIA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 304748907 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9125372020 | ||||||||
| FaxNumber: | 9125377935 | ||||||||
| Practice Location | |||||||||
| Address1: | 18 LUCKIE ST STE C | ||||||||
| Address2: | SUTIE C | ||||||||
| City: | BAXLEY | ||||||||
| State: | GA | ||||||||
| PostalCode: | 315130358 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9123676863 | ||||||||
| FaxNumber: | 9123670775 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2009 | ||||||||
| LastUpdateDate: | 05/11/2009 | ||||||||
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| AuthorizedOfficialLastName: | KANAVAGE | ||||||||
| AuthorizedOfficialFirstName: | EMILY | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 9125372020 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 1223 | GA | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
No ID Information.