Healthcare Provider Details

I. General information

NPI: 1487641858
Provider Name (Legal Business Name): NORTHEAST GEORGIA VISION CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/30/2005
Last Update Date: 09/25/2023
Certification Date: 09/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

118 VISION DR
CORNELIA GA
30531-5737
US

IV. Provider business mailing address

118 VISION DR
CORNELIA GA
30531-5737
US

V. Phone/Fax

Practice location:
  • Phone: 706-776-6311
  • Fax: 706-776-7243
Mailing address:
  • Phone: 706-776-6311
  • Fax: 706-776-7243

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1106
License Number StateGA

VIII. Authorized Official

Name: DR. HOLTON S KING JR.
Title or Position: PRESIDENT
Credential: OD
Phone: 706-776-2020