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General NPI Number Information
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NPI Number | 1003208711
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Entity Type | Organization
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Legal Business Name | OPTIQUE PCM
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Dates
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Enumeration Date | 03/04/2015
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Last Update Date | 08/28/2020
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Provider Practice Location Address
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Address Line | 650 NORTH AVE NE SUITE S103
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City | ATLANTA
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State | GA
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Zip | 30308-2705
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Country | US
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Telephone | 404-875-2766
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Fax |
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Provider Business Mailing Address
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Address Line | 1244 W PACES FERRY RD NW
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City | ATLANTA
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State | GA
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Zip | 30327-2306
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Country | US
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Telephone | 404-875-2766
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. GAVIN COHEN
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Credential | O.D.
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Telephone | 404-405-8539
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 1768
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License Number State | GA
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