Healthcare Provider Details

I. General information

NPI: 1780654483
Provider Name (Legal Business Name): EYE TO EYE VISION CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/25/2006
Last Update Date: 12/01/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2255 SEWELL MILL RD SUITE 310
MARIETTA GA
30062-2804
US

IV. Provider business mailing address

2255 SEWELL MILL RD SUITE 310
MARIETTA GA
30062-2804
US

V. Phone/Fax

Practice location:
  • Phone: 770-578-1900
  • Fax: 770-578-6623
Mailing address:
  • Phone: 770-578-1900
  • Fax: 770-578-6623

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number1332-T
License Number StateGA

VIII. Authorized Official

Name: DR. JEFFREY GLENN JERUSS
Title or Position: DOCTOR/OWNER
Credential: O.D.
Phone: 770-578-1900