Healthcare Provider Details

I. General information

NPI: 1780572933
Provider Name (Legal Business Name): MARIETTA EYE OPTICAL INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/26/2025
Last Update Date: 06/26/2025
Certification Date: 06/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4025 JOHNS CREEK PKWY
SUWANEE GA
30024-5682
US

IV. Provider business mailing address

895 CANTON RD NE BLDG 100
MARIETTA GA
30060-8935
US

V. Phone/Fax

Practice location:
  • Phone: 770-427-8111
  • Fax:
Mailing address:
  • Phone: 770-427-8111
  • Fax: 770-499-1643

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number
License Number State

VIII. Authorized Official

Name: REBECCA THACKSTON
Title or Position: MANAGER
Credential:
Phone: 770-427-8111