Healthcare Provider Details

I. General information

NPI: 1366429599
Provider Name (Legal Business Name): BEALL OPTICAL INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/29/2005
Last Update Date: 12/11/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3001 N ASHLEY ST
VALDOSTA GA
31602-1709
US

IV. Provider business mailing address

3001 N ASHLEY ST
VALDOSTA GA
31602-1709
US

V. Phone/Fax

Practice location:
  • Phone: 229-247-8484
  • Fax: 229-247-7996
Mailing address:
  • Phone: 229-247-8484
  • Fax: 229-247-7996

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156FX1800X
TaxonomyOptician
License Number598
License Number StateGA

VIII. Authorized Official

Name: MR. STEPHEN ALLEN BEALL
Title or Position: OWNER
Credential: LDO
Phone: 229-247-8484