Healthcare Provider Details

I. General information

NPI: 1659550515
Provider Name (Legal Business Name): OPTIQUE AT WEST PACES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/29/2007
Last Update Date: 11/07/2025
Certification Date: 11/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1244 W PACES FERRY RD NW
ATLANTA GA
30327-2306
US

IV. Provider business mailing address

1244 W PACES FERRY RD NW
ATLANTA GA
30327-2306
US

V. Phone/Fax

Practice location:
  • Phone: 404-844-1500
  • Fax: 404-844-2700
Mailing address:
  • Phone: 404-844-1500
  • Fax: 404-844-2700

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1768
License Number StateGA

VIII. Authorized Official

Name: GAVIN COHEN
Title or Position: OWNER
Credential:
Phone: 404-844-1500