Healthcare Provider Details

I. General information

NPI: 1316009616
Provider Name (Legal Business Name): MARIETTA EYE CLINIC, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/14/2006
Last Update Date: 05/15/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 OLD BALL GROUND HWY
CANTON GA
30114
US

IV. Provider business mailing address

895 CANTON RD NE BUILDING 100
MARIETTA GA
30060-8934
US

V. Phone/Fax

Practice location:
  • Phone: 770-479-2195
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number
License Number State

VIII. Authorized Official

Name: HENRY ELLIOTT GATEHOUSE
Title or Position: SENIOR DIRECTOR
Credential:
Phone: 770-427-8111