=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053100578
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CRESCENT EYE CARE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/01/2025
-----------------------------------------------------
Last Update Date | 05/01/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 673 W WASHINGTON ST
-----------------------------------------------------
City | MONTICELLO
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31064-1371
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-468-8598
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 105 CRESCENT DR
-----------------------------------------------------
City | FORSYTH
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31029-5464
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 478-233-0869
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OPTOMETRIST
-----------------------------------------------------
Name | JARVIS D JOHNSON
-----------------------------------------------------
Credential | OD
-----------------------------------------------------
Telephone | 478-233-0869
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------