Basic Information
| Provider Information | |||||||||
| NPI: | 1952470072 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ATLANTA EYE PROSTHETICS INCORPORATED | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 724928 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 311399028 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6788381585 | ||||||||
| FaxNumber: | 6788381587 | ||||||||
| Practice Location | |||||||||
| Address1: | 6065 ROSWELL RD NE | ||||||||
| Address2: | SUITE 420 NORTHSIDE TOWER | ||||||||
| City: | SANDY SPRINGS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303284014 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4043524550 | ||||||||
| FaxNumber: | 4043525833 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/06/2006 | ||||||||
| LastUpdateDate: | 03/22/2013 | ||||||||
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| AuthorizedOfficialLastName: | HERNDON | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER BOARD CERTIFIED OCULARIST | ||||||||
| AuthorizedOfficialTelephone: | 4043524550 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | B.C.O. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | 119660-8 | GA | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
ID Information
| ID | Type | State | Issuer | Description | 000411166A | 05 | GA | MEDICAID | 0758420001 | 01 | GA | MEDICARE SUPPLIER BILLING NUMBER | OTHER |