Basic Information
| Provider Information | |||||||||
| NPI: | 1376610618 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | AMERICAN EYECARE CENTER OF JESUP INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 198 SW BROAD ST | ||||||||
| Address2: | |||||||||
| City: | JESUP | ||||||||
| State: | GA | ||||||||
| PostalCode: | 315451101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9125306000 | ||||||||
| FaxNumber: | 9125306044 | ||||||||
| Practice Location | |||||||||
| Address1: | 198 SW BROAD ST | ||||||||
| Address2: | |||||||||
| City: | JESUP | ||||||||
| State: | GA | ||||||||
| PostalCode: | 315451101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9125306000 | ||||||||
| FaxNumber: | 9125306044 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/30/2006 | ||||||||
| LastUpdateDate: | 03/26/2013 | ||||||||
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| AuthorizedOfficialLastName: | THOMAS | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | DERRYL | ||||||||
| AuthorizedOfficialTitleorPosition: | PRES. | ||||||||
| AuthorizedOfficialTelephone: | 9125306000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | O.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 00461876B | 05 | GA | MEDICAID | 00461876D | 05 | GA | MEDICAID | 410026823 | 01 | GA | RAILROAD MEDICARE | OTHER |