Basic Information
| Provider Information | |||||||||
| NPI: | 1538466891 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EYEWORKS OF ATLANTA, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 800 PEACHTREE STREET | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30308 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4043773937 | ||||||||
| FaxNumber: | 4043773936 | ||||||||
| Practice Location | |||||||||
| Address1: | 800 PEACHTREE ST | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303081245 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4043773937 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/23/2011 | ||||||||
| LastUpdateDate: | 02/23/2011 | ||||||||
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| AuthorizedOfficialLastName: | ROMAN | ||||||||
| AuthorizedOfficialFirstName: | LUIS | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OPTICIAN | ||||||||
| AuthorizedOfficialTelephone: | 4043773937 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | LDO | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | LDO002182 | GA | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
No ID Information.