Healthcare Provider Details

I. General information

NPI: 1831321207
Provider Name (Legal Business Name): MARIETTA EYE OPTICAL INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/18/2009
Last Update Date: 04/03/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4450 CALIBRE CROSSING, NW. SUITE 1104
ACWORTH GA
30101-4108
US

IV. Provider business mailing address

895 CANTON RD NE BLDG 100
MARIETTA GA
30060-8934
US

V. Phone/Fax

Practice location:
  • Phone: 678-279-1141
  • Fax: 678-279-1147
Mailing address:
  • Phone: 770-427-8111
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: TIA MCENTIRE
Title or Position: OPTICAL DIRECTOR
Credential:
Phone: 678-784-0242