Healthcare Provider Details

I. General information

NPI: 1710293899
Provider Name (Legal Business Name): CALHOUN EYE CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/26/2010
Last Update Date: 08/26/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 S COURT ST
CALHOUN GA
30701-2296
US

IV. Provider business mailing address

100 S COURT ST
CALHOUN GA
30701-2296
US

V. Phone/Fax

Practice location:
  • Phone: 706-629-8266
  • Fax: 706-629-8267
Mailing address:
  • Phone: 706-629-8266
  • Fax: 706-629-8267

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156FX1800X
TaxonomyOptician
License NumberLDO000772
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License NumberLDO000772
License Number StateGA

VIII. Authorized Official

Name: MS. GINGER R WORDE
Title or Position: OPTICIAN
Credential: LDO
Phone: 706-629-8266