Healthcare Provider Details

I. General information

NPI: 1326992132
Provider Name (Legal Business Name): JESSICA SARAH CHAVEZ LDO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/26/2026
Last Update Date: 02/26/2026
Certification Date: 02/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4469 WASHINGTON RD
EVANS GA
30809-3807
US

IV. Provider business mailing address

4469 WASHINGTON RD
EVANS GA
30809-3807
US

V. Phone/Fax

Practice location:
  • Phone: 706-854-7779
  • Fax: 706-854-7668
Mailing address:
  • Phone: 706-854-7779
  • Fax: 706-854-7668

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156FX1800X
TaxonomyOptician
License NumberLDO003098
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: