Healthcare Provider Details

I. General information

NPI: 1144530833
Provider Name (Legal Business Name): SPENCER EYE CARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/14/2010
Last Update Date: 10/14/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

596 BOBBY JONES EXPY
AUGUSTA GA
30907-5300
US

IV. Provider business mailing address

2622 SERENITY LN
AUGUSTA GA
30909-0646
US

V. Phone/Fax

Practice location:
  • Phone: 706-863-1150
  • Fax:
Mailing address:
  • Phone: 703-342-8889
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2562
License Number StateGA

VIII. Authorized Official

Name: DR. ALEXIS DANIELLE SPENCER
Title or Position: OPTOMETRIST
Credential: O.D.
Phone: 703-342-8889