Healthcare Provider Details

I. General information

NPI: 1376217026
Provider Name (Legal Business Name): MEL OPTICAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/05/2021
Last Update Date: 08/05/2021
Certification Date: 08/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3245 COBB PKWY NW STE 105
ACWORTH GA
30101-3949
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: 956-335-6476
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number State

VIII. Authorized Official

Name: DANIEL GARZA
Title or Position: CREDENTIALING MANAGER
Credential:
Phone: 210-843-1393