Healthcare Provider Details

I. General information

NPI: 1104010594
Provider Name (Legal Business Name): ROSWELL EYE CLINIC,INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/29/2007
Last Update Date: 02/28/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1190 GRIMES BRIDGE RD
ROSWELL GA
30075-3930
US

IV. Provider business mailing address

1190 GRIMES BRIDGE RD
ROSWELL GA
30075-3930
US

V. Phone/Fax

Practice location:
  • Phone: 770-992-7620
  • Fax: 770-992-8262
Mailing address:
  • Phone: 770-992-7620
  • Fax: 770-992-8262

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number861-T
License Number StateGA

VIII. Authorized Official

Name: DR. SHARON B MOSCOW
Title or Position: OPTOMETRIST
Credential:
Phone: 770-992-7620