Basic Information
| Provider Information | |||||||||
| NPI: | 1063680833 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SURESIGHT AND ASSOCIATES L L C | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | SURESIGHT EYECARE CANTON | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 217 RIVERSTONE DR | ||||||||
| Address2: | |||||||||
| City: | CANTON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301145256 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7703455220 | ||||||||
| FaxNumber: | 7704795011 | ||||||||
| Practice Location | |||||||||
| Address1: | 217 RIVERSTONE DR | ||||||||
| Address2: | |||||||||
| City: | CANTON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301145256 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7703455220 | ||||||||
| FaxNumber: | 7704795011 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/14/2008 | ||||||||
| LastUpdateDate: | 04/02/2009 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WAYLAND | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | JACKSON | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7703455220 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | SR. | ||||||||
| AuthorizedOfficialCredential: | O.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QS0132X | GA1769 | GA | N | Ambulatory Health Care Facilities | Clinic/Center | Ophthalmologic Surgery | 152W00000X | OPT0001624 | GA | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
No ID Information.