Healthcare Provider Details

I. General information

NPI: 1265198881
Provider Name (Legal Business Name): ATL OPTICAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/09/2021
Last Update Date: 11/09/2021
Certification Date: 10/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5413 US-280 SUITE 103
HOOVER AL
35242
US

IV. Provider business mailing address

1943 PLEASANT HILL RD
DULUTH GA
30096-4625
US

V. Phone/Fax

Practice location:
  • Phone: 956-335-6476
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number StateNULL

VIII. Authorized Official

Name: JACKIE BENNETT
Title or Position: CREDENTIALING SUPERVISOR
Credential:
Phone: 561-443-6009