Basic Information
| Provider Information | |||||||||
| NPI: | 1699888131 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | EYE CARE CENTERS MANAGEMENT INC | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | CLAYTON EYE CENTER OR SPALDING EYE CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1000 CORPORATE CENTER DR | ||||||||
| Address2: | STE 100 | ||||||||
| City: | MORROW | ||||||||
| State: | GA | ||||||||
| PostalCode: | 302604180 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7709688888 | ||||||||
| FaxNumber: | 7709602473 | ||||||||
| Practice Location | |||||||||
| Address1: | 1000 CORPORATE CENTER DR | ||||||||
| Address2: | STE 100 | ||||||||
| City: | MORROW | ||||||||
| State: | GA | ||||||||
| PostalCode: | 302604180 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7709688888 | ||||||||
| FaxNumber: | 7709602473 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/17/2006 | ||||||||
| LastUpdateDate: | 03/31/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | KIM | ||||||||
| AuthorizedOfficialFirstName: | JOON | ||||||||
| AuthorizedOfficialMiddleName: | Y | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7709688888 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 03/31/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332H00000X | 016040001 | GA | N | Suppliers | Eyewear Supplier (Equipment, not the service) | 152W00000X | N | 193200000X MULTI-SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist | 207W00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Ophthalmology |
ID Information
| ID | Type | State | Issuer | Description | C16012 | 01 | GA | RAILROAD MEDICARE | OTHER | 300027085A | 05 | GA | MEDICAID |