Healthcare Provider Details

I. General information

NPI: 1154569069
Provider Name (Legal Business Name): FAMILY EYE CARE CENTER OF ATLANTA, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/30/2009
Last Update Date: 01/30/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 SOUTHLAKE MALL
MORROW GA
30260-2328
US

IV. Provider business mailing address

1270 CAROLINE ST NE SUITE D120-377
ATLANTA GA
30307-2758
US

V. Phone/Fax

Practice location:
  • Phone: 678-422-1936
  • Fax: 678-422-1936
Mailing address:
  • Phone: 202-320-7373
  • Fax: 678-298-9903

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License NumberOPT002490
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code152WS0006X
TaxonomySports Vision Optometrist
License NumberOPT002490
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code152WV0400X
TaxonomyVision Therapy Optometrist
License NumberOPT002490
License Number StateGA
# 4
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPT002490
License Number StateGA

VIII. Authorized Official

Name: DR. TAKEIA J LOCKE
Title or Position: CEO
Credential: OD
Phone: 202-320-7373