Healthcare Provider Details

I. General information

NPI: 1215875802
Provider Name (Legal Business Name): LEGACY FAMILY EYECARE AT FLOWERY BRANCH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/24/2026
Last Update Date: 03/24/2026
Certification Date: 03/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5900 SPOUT SPRINGS RD STE I9
FLOWERY BRANCH GA
30542-6447
US

IV. Provider business mailing address

5900 SPOUT SPRINGS RD STE I9
FLOWERY BRANCH GA
30542-6447
US

V. Phone/Fax

Practice location:
  • Phone: 770-965-2401
  • Fax: 770-965-2546
Mailing address:
  • Phone: 770-965-2401
  • Fax: 770-965-2546

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MICHAEL ROBERTS
Title or Position: OWNER
Credential: OD
Phone: 404-918-6238