Healthcare Provider Details

I. General information

NPI: 1619093531
Provider Name (Legal Business Name): GWINNETT EYE CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/22/2007
Last Update Date: 02/25/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3455 PEACHTREE INDUSTRIAL BLVD SUITE 845
DULUTH GA
30096-6501
US

IV. Provider business mailing address

3455 PEACHTREE INDUSTRIAL BLVD SUITE 845
DULUTH GA
30096-6501
US

V. Phone/Fax

Practice location:
  • Phone: 770-476-3606
  • Fax: 770-476-2818
Mailing address:
  • Phone: 770-476-3606
  • Fax: 770-476-2818

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPT000841
License Number State

VIII. Authorized Official

Name: KAREN E PITTS
Title or Position: MGN
Credential:
Phone: 770-476-3606