Healthcare Provider Details

I. General information

NPI: 1861871725
Provider Name (Legal Business Name): THE EYECARE PLACE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/26/2015
Last Update Date: 05/26/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

42 OLD JACKSON RD
MCDONOUGH GA
30252-3029
US

IV. Provider business mailing address

42 OLD JACKSON RD
MCDONOUGH GA
30252-3029
US

V. Phone/Fax

Practice location:
  • Phone: 678-782-7952
  • Fax: 678-782-7954
Mailing address:
  • Phone: 678-782-7952
  • Fax: 678-782-7954

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPT001522
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code156FX1800X
TaxonomyOptician
License NumberLDO002144
License Number StateGA

VIII. Authorized Official

Name: CHHAYA SEI
Title or Position: CEO/MANAGER
Credential: LDO
Phone: 678-782-7952