Basic Information
Provider Information | |||||||||
NPI: | 1225333040 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | EYEWORKS GA, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 335 W PONCE DE LEON AVE | ||||||||
Address2: | SUITE F | ||||||||
City: | DECATUR | ||||||||
State: | GA | ||||||||
PostalCode: | 300302451 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4043773937 | ||||||||
FaxNumber: | 4043773936 | ||||||||
Practice Location | |||||||||
Address1: | 335 W PONCE DE LEON AVE | ||||||||
Address2: | SUITE F | ||||||||
City: | DECATUR | ||||||||
State: | GA | ||||||||
PostalCode: | 300302451 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4043773937 | ||||||||
FaxNumber: | 4043773936 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/26/2011 | ||||||||
LastUpdateDate: | 01/26/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | ROMAN | ||||||||
AuthorizedOfficialFirstName: | LUIS | ||||||||
AuthorizedOfficialMiddleName: | F | ||||||||
AuthorizedOfficialTitleorPosition: | OPTICIAN | ||||||||
AuthorizedOfficialTelephone: | 4043773937 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | LDO | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | LDO002182 | FL | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |   |
No ID Information.