Healthcare Provider Details

I. General information

NPI: 1578210589
Provider Name (Legal Business Name): GWINNETT PEDIATRIC & ADULT EYE CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/09/2022
Last Update Date: 10/04/2023
Certification Date: 10/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 PEACHTREE INDUSTRIAL BLVD STE 1206
SUWANEE GA
30024-4550
US

IV. Provider business mailing address

1300 PEACHTREE INDUSTRIAL BLVD STE 1206
SUWANEE GA
30024-4550
US

V. Phone/Fax

Practice location:
  • Phone: 334-318-0713
  • Fax:
Mailing address:
  • Phone: 770-783-2162
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State

VIII. Authorized Official

Name: SHUNDALE THOMAS MIXON
Title or Position: OWNER/OD
Credential:
Phone: 770-783-2162