Healthcare Provider Details

I. General information

NPI: 1992042972
Provider Name (Legal Business Name): OPTICA LATINA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/10/2013
Last Update Date: 01/10/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4485 LAWRENCEVILLE HWY NW SUITE 206
LILBURN GA
30047-3669
US

IV. Provider business mailing address

4485 LAWRENCEVILLE HWY NW SUITE 206
LILBURN GA
30047-3669
US

V. Phone/Fax

Practice location:
  • Phone: 770-674-1712
  • Fax: 770-687-2921
Mailing address:
  • Phone: 770-674-1712
  • Fax: 770-687-2921

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPT002681
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code156FX1800X
TaxonomyOptician
License NumberLDO001948
License Number StateGA

VIII. Authorized Official

Name: LEONEL E COELLO
Title or Position: OWNER
Credential: LDO
Phone: 770-815-1915