Healthcare Provider Details

I. General information

NPI: 1154169985
Provider Name (Legal Business Name): BOLT EYE GROUP - LAWRENCEVILLE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/16/2024
Last Update Date: 07/16/2024
Certification Date: 07/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

575 PROFESSIONAL DR
LAWRENCEVILLE GA
30046-3333
US

IV. Provider business mailing address

575 PROFESSIONAL DR
LAWRENCEVILLE GA
30046-3333
US

V. Phone/Fax

Practice location:
  • Phone: 678-993-2020
  • Fax:
Mailing address:
  • Phone: 678-993-2020
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: BARBRA WILLIAMS
Title or Position: COO
Credential:
Phone: 770-776-9000