Healthcare Provider Details

I. General information

NPI: 1427159821
Provider Name (Legal Business Name): PHI PHI BANG O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/26/2006
Last Update Date: 01/24/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1675 CUMBERLAND PKWY SE SUITE #103
SMYRNA GA
30080-6359
US

IV. Provider business mailing address

15933 CLAYTON RD SUITE 201
BALLWIN MO
63011-2172
US

V. Phone/Fax

Practice location:
  • Phone: 770-438-0202
  • Fax:
Mailing address:
  • Phone: 636-200-4393
  • Fax: 636-527-0766

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number2015
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: