Healthcare Provider Details

I. General information

NPI: 1194988220
Provider Name (Legal Business Name): EYE SURGERY CENTER OF ALBANY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/09/2008
Last Update Date: 07/09/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2308 PALMYRA RD
ALBANY GA
31701-1324
US

IV. Provider business mailing address

2308 PALMYRA RD
ALBANY GA
31701-1324
US

V. Phone/Fax

Practice location:
  • Phone: 229-435-8799
  • Fax: 229-438-8345
Mailing address:
  • Phone: 229-435-8799
  • Fax: 229-438-8345

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QS0132X
TaxonomyOphthalmologic Surgery Clinic/Center
License Number047-325
License Number StateGA

VIII. Authorized Official

Name: MR. SCOT ALLEN WALL
Title or Position: PRESIDENT
Credential: MD
Phone: 229-435-8799