Healthcare Provider Details

I. General information

NPI: 1235127986
Provider Name (Legal Business Name): KENNETH G SCHNEIDER O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/06/2005
Last Update Date: 01/27/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

72 FALLS RD
TOCCOA GA
30577-1653
US

IV. Provider business mailing address

72 FALLS RD
TOCCOA GA
30577-1653
US

V. Phone/Fax

Practice location:
  • Phone: 706-886-2120
  • Fax: 706-886-2646
Mailing address:
  • Phone: 706-886-2120
  • Fax: 706-886-2646

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number741
License Number StateGA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier00004562B
Identifier TypeMEDICAID
Identifier StateGA
Identifier Issuer
# 2
Identifier0066145
Identifier TypeOTHER
Identifier StateGA
Identifier IssuerCIGNA
# 3
Identifier202I417677
Identifier TypeOTHER
Identifier StateGA
Identifier IssuerMEDICARE PTAN
# 4
Identifier24288
Identifier TypeOTHER
Identifier StateGA
Identifier IssuerBLUE CROSS BLUE SHEILD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: