Healthcare Provider Details

I. General information

NPI: 1417673591
Provider Name (Legal Business Name): SOUTHERN OCULAR PROSTHETICS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/19/2022
Last Update Date: 10/19/2022
Certification Date: 10/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2801 N DECATUR RD STE 130
DECATUR GA
30033-6049
US

IV. Provider business mailing address

6065 ROSWELL RD STE 870
SANDY SPRINGS GA
30328-4065
US

V. Phone/Fax

Practice location:
  • Phone: 470-296-2152
  • Fax:
Mailing address:
  • Phone: 559-940-1189
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156FX1700X
TaxonomyOcularist
License Number
License Number State

VIII. Authorized Official

Name: ANTONIO LOUIS ALCORTA I
Title or Position: PRESIDENT
Credential: BCO BADO
Phone: 559-940-1189