Healthcare Provider Details

I. General information

NPI: 1639092471
Provider Name (Legal Business Name): ANDERSON OPTICAL, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/30/2026
Last Update Date: 07/30/2026
Certification Date: 07/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 US HIGHWAY 80 W UNIT A
POOLER GA
31322-2504
US

IV. Provider business mailing address

104 US HIGHWAY 80 W UNIT A
POOLER GA
31322-2504
US

V. Phone/Fax

Practice location:
  • Phone: 912-330-1200
  • Fax:
Mailing address:
  • Phone: 912-330-1200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. ROBERT CHARLES ANDERSON
Title or Position: LICENSED DISPENSING OPTICIAN
Credential:
Phone: 912-330-1200