Healthcare Provider Details

I. General information

NPI: 1639299563
Provider Name (Legal Business Name): FAMILY EYE CARE OF TOCCOA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/02/2007
Last Update Date: 08/11/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

58 E DOYLE ST
TOCCOA GA
30577-3009
US

IV. Provider business mailing address

58 E DOYLE ST
TOCCOA GA
30577-3009
US

V. Phone/Fax

Practice location:
  • Phone: 706-886-5214
  • Fax: 706-282-1451
Mailing address:
  • Phone: 706-886-5214
  • Fax: 706-282-1451

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPT001460
License Number StateGA

VII. Legacy identifiers

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

# 1
IdentifierDAG980
Identifier TypeMEDICAID
Identifier StateSC
Identifier Issuer
# 2
Identifier00626216B
Identifier TypeMEDICAID
Identifier StateGA
Identifier Issuer

VIII. Authorized Official

Name: KAY ROYAL
Title or Position: PRESIDENT
Credential: OD
Phone: 706-886-5214