Healthcare Provider Details

I. General information

NPI: 1255399184
Provider Name (Legal Business Name): RAINEY PROFESSIONAL ASSOCIATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/02/2006
Last Update Date: 12/07/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

208 SMITH ST
LAGRANGE GA
30240-2755
US

IV. Provider business mailing address

208 SMITH ST
LAGRANGE GA
30240-2755
US

V. Phone/Fax

Practice location:
  • Phone: 706-882-0166
  • Fax: 706-883-7363
Mailing address:
  • Phone: 706-882-0166
  • Fax: 706-883-7363

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberJ508003
License Number StateGA

VIII. Authorized Official

Name: MRS. PAT HILL
Title or Position: OFFICE MANAGER
Credential:
Phone: 706-882-0166