Healthcare Provider Details

I. General information

NPI: 1518693878
Provider Name (Legal Business Name): BOLT EYE GROUP-CANTON LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/28/2022
Last Update Date: 07/18/2023
Certification Date: 07/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2060 CUMMING HWY STE 400
CANTON GA
30115-3793
US

IV. Provider business mailing address

4180 OLD MILTON
ALPHARETTA GA
30005
US

V. Phone/Fax

Practice location:
  • Phone: 770-615-2007
  • Fax: 770-615-6242
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State

VIII. Authorized Official

Name: SUSAN REIMBOLD
Title or Position: OPTOMETRIST
Credential: O.D.
Phone: 770-776-9000