Healthcare Provider Details

I. General information

NPI: 1366743965
Provider Name (Legal Business Name): EYEGLASS WORLD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/12/2010
Last Update Date: 11/12/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2377 E MAIN ST STE 130
PLAINFIELD IN
46168-2824
US

IV. Provider business mailing address

296 GRAYSON HWY
LAWRENCEVILLE GA
30046-5737
US

V. Phone/Fax

Practice location:
  • Phone: 317-839-5658
  • Fax: 317-839-6059
Mailing address:
  • Phone: 770-822-3600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156FX1800X
TaxonomyOptician
License Number
License Number State

VII. Legacy identifiers

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

VIII. Authorized Official

Name: SUSAN EDICK
Title or Position: MC ASSISTANT
Credential:
Phone: 678-892-3774