Healthcare Provider Details

I. General information

NPI: 1659789923
Provider Name (Legal Business Name): PEDIATRIC VISION DEVELOPMENT CENTER OF FORSYTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/30/2014
Last Update Date: 07/30/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2920 RONALD REAGAN BLVD STE 104
CUMMING GA
30041-6206
US

IV. Provider business mailing address

3452 LAKE MILL RD
BUFORD GA
30519-5349
US

V. Phone/Fax

Practice location:
  • Phone: 770-904-0979
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152WV0400X
TaxonomyVision Therapy Optometrist
License Number2353
License Number StateGA

VIII. Authorized Official

Name: DR. JOSEPH ROUW
Title or Position: OWNER
Credential: OD
Phone: 678-448-2854