Basic Information
| Provider Information | |||||||||
| NPI: | 1679953293 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | B3 OPTICAL LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 128 N PARK DR | ||||||||
| Address2: | |||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 302141645 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7704741237 | ||||||||
| FaxNumber: | 7704745224 | ||||||||
| Practice Location | |||||||||
| Address1: | 550 EALES LANDING PARKWAY | ||||||||
| Address2: | SUITE 208 | ||||||||
| City: | STOCKBRIDGE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 302819082 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7704741237 | ||||||||
| FaxNumber: | 7704745224 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2015 | ||||||||
| LastUpdateDate: | 06/09/2015 | ||||||||
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| AuthorizedOfficialLastName: | DEPOE | ||||||||
| AuthorizedOfficialFirstName: | LAURA | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7704741237 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | OD | ||||||||
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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 |
No ID Information.