Healthcare Provider Details

I. General information

NPI: 1487719084
Provider Name (Legal Business Name): MODERN EYECARE OF MEDLOCK
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/25/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9700 MEDLOCK BRIDGE RD SUITE 182
DULUTH GA
30097-4411
US

IV. Provider business mailing address

190 BRIGHTMORE WAY
ALPHARETTA GA
30005-6773
US

V. Phone/Fax

Practice location:
  • Phone: 678-205-1599
  • Fax: 678-205-1632
Mailing address:
  • Phone: 678-205-1599
  • Fax: 678-205-1632

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License NumberOPT002001
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPT002001
License Number StateGA

VIII. Authorized Official

Name: GRACE K WOO
Title or Position: MANAGING MEMEBER
Credential:
Phone: 678-205-1599