Healthcare Provider Details

I. General information

NPI: 1346357928
Provider Name (Legal Business Name): CARROLLTON EYE CLINIC, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/23/2006
Last Update Date: 12/16/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

158 CLINIC AVE
CARROLLTON GA
30117-4414
US

IV. Provider business mailing address

158 CLINIC AVE
CARROLLTON GA
30117-4414
US

V. Phone/Fax

Practice location:
  • Phone: 770-834-1008
  • Fax: 770-834-2531
Mailing address:
  • Phone: 770-834-1008
  • Fax: 770-834-2531

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. ANGIE BRADLEY
Title or Position: ADMINISTRATOR
Credential:
Phone: 770-834-1008