Healthcare Provider Details

I. General information

NPI: 1023722188
Provider Name (Legal Business Name): BOLT EYE GROUP - GAINESVILLE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/12/2023
Last Update Date: 04/05/2023
Certification Date: 04/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 SHERWOOD PARK DR NE
GAINESVILLE GA
30501-3444
US

IV. Provider business mailing address

4180 OLD MILTON PKWY STE 1D
ALPHARETTA GA
30005-2408
US

V. Phone/Fax

Practice location:
  • Phone: 770-536-3231
  • Fax:
Mailing address:
  • Phone: 770-776-9000
  • Fax: 678-293-8499

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: SUSAN MARIE REIMBOLD
Title or Position: OWNER
Credential: OD
Phone: 770-776-9000