Healthcare Provider Details

I. General information

NPI: 1508900879
Provider Name (Legal Business Name): PICKENS EYE CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/19/2007
Last Update Date: 06/24/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

360 W CHURCH ST
JASPER GA
30143-1400
US

IV. Provider business mailing address

360 W CHURCH ST
JASPER GA
30143-1400
US

V. Phone/Fax

Practice location:
  • Phone: 706-692-2878
  • Fax: 706-692-2879
Mailing address:
  • Phone: 706-692-2878
  • Fax: 706-692-2879

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: PAT BLACK
Title or Position: INSURANCE MANAGER
Credential:
Phone: 706-692-2878