Basic Information
| Provider Information | |||||||||
| NPI: | 1598181034 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | OPTIQUE ATLANTA, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2549 PIEDMONT RD NE | ||||||||
| Address2: | SUITE 120 | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303243023 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6789392709 | ||||||||
| FaxNumber: | 4046010795 | ||||||||
| Practice Location | |||||||||
| Address1: | 2549 PIEDMONT RD NE | ||||||||
| Address2: | SUITE 120 | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303243023 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6789392709 | ||||||||
| FaxNumber: | 4046010795 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/07/2014 | ||||||||
| LastUpdateDate: | 03/07/2014 | ||||||||
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| AuthorizedOfficialLastName: | MORESI | ||||||||
| AuthorizedOfficialFirstName: | PETER | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT/SOLE MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 6789392709 | ||||||||
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| 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 | GA | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
No ID Information.