Healthcare Provider Details

I. General information

NPI: 1699888131
Provider Name (Legal Business Name): EYE CARE CENTERS MANAGEMENT INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/17/2006
Last Update Date: 03/31/2021
Certification Date: 03/31/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 CORPORATE CENTER DR STE 100
MORROW GA
30260-4180
US

IV. Provider business mailing address

1000 CORPORATE CENTER DR STE 100
MORROW GA
30260-4180
US

V. Phone/Fax

Practice location:
  • Phone: 770-968-8888
  • Fax: 770-960-2473
Mailing address:
  • Phone: 770-968-8888
  • Fax: 770-960-2473

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number016040001
License Number StateGA

VIII. Authorized Official

Name: JOON Y KIM
Title or Position: OWNER
Credential: MD
Phone: 770-968-8888