Healthcare Provider Details

I. General information

NPI: 1992031074
Provider Name (Legal Business Name): MIDTOWNE VISION CENTER, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/26/2009
Last Update Date: 09/30/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

635 PIO NONO AVE
MACON GA
31204-3531
US

IV. Provider business mailing address

635 PIO NONO AVE
MACON GA
31204-3531
US

V. Phone/Fax

Practice location:
  • Phone: 478-803-0001
  • Fax: 478-254-4997
Mailing address:
  • Phone: 478-803-0001
  • Fax: 478-254-4997

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number002520
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License Number1471
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License Number002520
License Number StateGA
# 4
Primary TaxonomyN
Taxonomy Code152WV0400X
TaxonomyVision Therapy Optometrist
License Number002520
License Number StateGA
# 5
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1471
License Number StateGA

VIII. Authorized Official

Name: DR. MIRIAM D TURNER
Title or Position: OFFICE ADMINISTRATOR
Credential: OD
Phone: 478-803-0001