MEDICARE: ATLANTA EYE SHOP, INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	OPT001650GA	GA

General Provider Information

NPI Number	:	1578901781
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ATLANTA EYE SHOP, INC

Provider Business Mailing Address
First Line	:	3621 VININGS SLOPE SE
Second Line	:	SUITE 4190
City	:	ATLANTA
State	:	GA
Zip	:	30339-4107
Country	:	US
Telephone Number	:	678-310-0166
Fax Number	:	678-310-0168

Provider Business Practice Location Address
First Line	:	3621 VININGS SLOPE SE
Second Line	:	SUITE 4190
City	:	ATLANTA
State	:	GA
Zip	:	30339-4107
Country	:	US
Telephone Number	:	678-310-0166
Fax Number	:	678-310-0168

Authorized Official
Title or Position	:	OWNER
Name	:	YUCHONG SMITH
Credential	:	OD
Telephone Number	:	678-310-0166

Provider Enumeration Date	:	06/10/2013
Last Update Date	:	06/10/2013

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Directions to “ATLANTA EYE SHOP, INC ” Practice Location

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