Healthcare Provider Details

I. General information

NPI: 1497882500
Provider Name (Legal Business Name): NORTH GEORGIA EYE CLINIC, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/27/2007
Last Update Date: 10/26/2021
Certification Date: 06/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1485 JESSE JEWELL PARKWAY NE SUITE 100
GAINESVILLE GA
30501-3806
US

IV. Provider business mailing address

1485 JESSE JEWELL PARKWAY NE SUITE 100
GAINESVILLE GA
30501-3806
US

V. Phone/Fax

Practice location:
  • Phone: 770-534-1711
  • Fax: 770-534-9158
Mailing address:
  • Phone: 770-534-1711
  • Fax: 770-534-9158

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code152WL0500X
TaxonomyLow Vision Rehabilitation Optometrist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code156FC0800X
TaxonomyContact Lens Technician/Technologist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code156FX1800X
TaxonomyOptician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code156FX1900X
TaxonomyOrthoptist
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number
License Number State
# 7
Primary TaxonomyY
Taxonomy Code156FX1100X
TaxonomyOphthalmic Technician/Technologist
License Number
License Number State

VIII. Authorized Official

Name: DR. LARRY J PAYNE
Title or Position: PRESIDENT
Credential: M.D.
Phone: 770-534-1711