Healthcare Provider Details

I. General information

NPI: 1376613968
Provider Name (Legal Business Name): SANTRELL DENISE HART-MORELAND O.D.,M.P.H.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/09/2006
Last Update Date: 11/16/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

158 FAIRVIEW RD SUITE B
ELLENWOOD GA
30294-2795
US

IV. Provider business mailing address

158 FAIRVIEW RD SUITE B
ELLENWOOD GA
30294-2795
US

V. Phone/Fax

Practice location:
  • Phone: 678-289-5835
  • Fax: 678-289-5837
Mailing address:
  • Phone: 678-289-5835
  • Fax: 678-289-5837

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number1761
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number001761
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number001761
License Number StateGA
# 4
Primary TaxonomyN
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License Number001761
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: