Healthcare Provider Details

I. General information

NPI: 1477183028
Provider Name (Legal Business Name): ATL OPTICAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/23/2020
Last Update Date: 02/19/2021
Certification Date: 02/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

166 CROSSROADS BLVD STE 100
DAWSONVILLE GA
30534-7868
US

IV. Provider business mailing address

1943 PLEASANT HILL RD
DULUTH GA
30096-4625
US

V. Phone/Fax

Practice location:
  • Phone: 404-448-4745
  • Fax: 561-828-8367
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number State

VIII. Authorized Official

Name: JACKIE BENNETT
Title or Position: CREDENTIALING MANAGER
Credential:
Phone: 619-357-6146