Healthcare Provider Details

I. General information

NPI: 1578901781
Provider Name (Legal Business Name): ATLANTA EYE SHOP, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/10/2013
Last Update Date: 06/10/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3621 VININGS SLOPE SE SUITE 4190
ATLANTA GA
30339-4107
US

IV. Provider business mailing address

3621 VININGS SLOPE SE SUITE 4190
ATLANTA GA
30339-4107
US

V. Phone/Fax

Practice location:
  • Phone: 678-310-0166
  • Fax: 678-310-0168
Mailing address:
  • Phone: 678-310-0166
  • Fax: 678-310-0168

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPT001650GA
License Number StateGA

VIII. Authorized Official

Name: YUCHONG SMITH
Title or Position: OWNER
Credential: OD
Phone: 678-310-0166