Healthcare Provider Details

I. General information

NPI: 1235118043
Provider Name (Legal Business Name): AUGUSTA RETINA LASER SURGICARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/10/2006
Last Update Date: 02/06/2025
Certification Date: 02/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3685 WHEELER RD SUITE 202
AUGUSTA GA
30909-6446
US

IV. Provider business mailing address

PO BOX 11407
BIRMINGHAM AL
35246-3035
US

V. Phone/Fax

Practice location:
  • Phone: 706-210-0305
  • Fax: 706-210-0306
Mailing address:
  • Phone: 706-210-0305
  • Fax: 706-210-0306

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number StateGA

VIII. Authorized Official

Name: MR. KEVIN BECKER
Title or Position: CFO
Credential:
Phone: 706-243-2259