Healthcare Provider Details

I. General information

NPI: 1265748222
Provider Name (Legal Business Name): DEPOE MANAGEMENT, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/27/2010
Last Update Date: 08/27/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 EAGLES LANDING PKWY SUITE 208
STOCKBRIDGE GA
30281-9081
US

IV. Provider business mailing address

550 EAGLES LANDING PKWY SUITE 208
STOCKBRIDGE GA
30281-9081
US

V. Phone/Fax

Practice location:
  • Phone: 770-474-1237
  • Fax: 770-474-5224
Mailing address:
  • Phone: 770-474-1237
  • Fax: 770-474-5224

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPT001305
License Number StateGA

VIII. Authorized Official

Name: DR. ADAM T. DEPOE
Title or Position: OWNER
Credential: O.D.
Phone: 770-474-1237