Basic Information
| Provider Information | |||||||||
| NPI: | 1265600035 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SURESIGHT EYECARE L.L.C. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SURESIGHT EYECARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3975 OLD MILTON PKWY | ||||||||
| Address2: | STE 2 | ||||||||
| City: | ALPHARETTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300054467 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6786247766 | ||||||||
| FaxNumber: | 6786247775 | ||||||||
| Practice Location | |||||||||
| Address1: | 3975 OLD MILTON PKWY | ||||||||
| Address2: | STE 2 | ||||||||
| City: | ALPHARETTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300054467 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6786247766 | ||||||||
| FaxNumber: | 6786247775 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/14/2008 | ||||||||
| LastUpdateDate: | 02/14/2008 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WAYLAND | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | JACKSON | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6786247766 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | SR. | ||||||||
| AuthorizedOfficialCredential: | O.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QS0132X | GA1624 | GA | Y | Ambulatory Health Care Facilities | Clinic/Center | Ophthalmologic Surgery |
No ID Information.