Basic Information
| Provider Information | |||||||||
| NPI: | 1821413006 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | OPTIQUE SANDY SPRINGS, LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | OPTIQUE ATLANTA | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5940 ROSWELL RD | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303284908 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6789392709 | ||||||||
| FaxNumber: | 4046010795 | ||||||||
| Practice Location | |||||||||
| Address1: | 5940 ROSWELL RD | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303284908 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6789392709 | ||||||||
| FaxNumber: | 4046010795 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/25/2014 | ||||||||
| LastUpdateDate: | 02/25/2014 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MORESI | ||||||||
| AuthorizedOfficialFirstName: | PETER | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT/SOLE MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 6789392709 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | O.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | OPT002496 | GA | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist | 152W00000X | OPT001083 | GA | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
No ID Information.