Healthcare Provider Details

I. General information

NPI: 1346390895
Provider Name (Legal Business Name): OPTICAL ILLUSIONS, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/10/2007
Last Update Date: 11/06/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

775 C KINGSBAY ROAD
ST MARYS GA
31558
US

IV. Provider business mailing address

775 C KINGSBAY ROAD
ST MARYS GA
31558
US

V. Phone/Fax

Practice location:
  • Phone: 912-729-6111
  • Fax: 912-729-8595
Mailing address:
  • Phone: 912-729-6111
  • Fax: 912-729-8595

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPT0001798
License Number StateGA

VIII. Authorized Official

Name: DR. IAN BUCHLI
Title or Position: CEO
Credential: O.D.
Phone: 912-729-6111