Healthcare Provider Details

I. General information

NPI: 1033236492
Provider Name (Legal Business Name): SUSAN MARIE REIMBOLD O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/23/2007
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4180 OLD MILTON PKWY SUITE 1-D
ALPHARETTA GA
30005-2408
US

IV. Provider business mailing address

4180 OLD MILTON PKWY SUITE 1-D
ALPHARETTA GA
30005-2408
US

V. Phone/Fax

Practice location:
  • Phone: 770-776-9000
  • Fax:
Mailing address:
  • Phone: 770-776-9000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number001567
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: