Healthcare Provider Details

I. General information

NPI: 1720845696
Provider Name (Legal Business Name): DANIEL OBREGON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/06/2024
Last Update Date: 03/06/2024
Certification Date: 03/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 LAWRENCEVILLE HWY STE 700
LAWRENCEVILLE GA
30044-2029
US

IV. Provider business mailing address

836 RIVER ROSE POINTE
DACULA GA
30019-1375
US

V. Phone/Fax

Practice location:
  • Phone: 770-682-7404
  • Fax:
Mailing address:
  • Phone: 770-533-1111
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156FX1800X
TaxonomyOptician
License NumberLDO002689
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: