Basic Information
| Provider Information | |||||||||
| NPI: | 1972533156 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LENOX EYE ASSOC PC | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | OPTICA UNIVERSAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2369 BUFORD HIGHWAY | ||||||||
| Address2: | SUITE 820 | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30329 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4043209100 | ||||||||
| FaxNumber: | 4042390298 | ||||||||
| Practice Location | |||||||||
| Address1: | 1418 DRESDEN DRIVE | ||||||||
| Address2: | SUITE 150 | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30309 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4048421950 | ||||||||
| FaxNumber: | 4042390298 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/04/2006 | ||||||||
| LastUpdateDate: | 12/17/2010 | ||||||||
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| AuthorizedOfficialLastName: | SORROW | ||||||||
| AuthorizedOfficialFirstName: | JULIE | ||||||||
| AuthorizedOfficialMiddleName: | ANN | ||||||||
| AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 4043209100 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | OPT001104 | GA | Y | 193200000X MULTI-SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 348726036B | 05 | GA | MEDICAID |