Healthcare Provider Details

I. General information

NPI: 1437791076
Provider Name (Legal Business Name): SHIPLEY & WAYLAND EYECARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/15/2019
Last Update Date: 10/15/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7768 CUMMING HWY STE 500
CANTON GA
30115-2984
US

IV. Provider business mailing address

192 GRANDMAR CHASE
CANTON GA
30115-6409
US

V. Phone/Fax

Practice location:
  • Phone: 470-863-1999
  • Fax:
Mailing address:
  • Phone: 404-784-4758
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code152WS0006X
TaxonomySports Vision Optometrist
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code152WX0102X
TaxonomyOccupational Vision Optometrist
License Number
License Number State

VIII. Authorized Official

Name: MISS ANESA CAFFEE
Title or Position: BILLING CONSULTANT
Credential:
Phone: 404-578-4550