=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093948309
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BRILLIANT EYES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/02/2009
-----------------------------------------------------
Last Update Date | 04/28/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2450 ATLANTA RD SE STE 200
-----------------------------------------------------
City | SMYRNA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30080-2073
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-428-0414
-----------------------------------------------------
Fax | 770-428-0415
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2450 ATLANTA RD SE STE 200
-----------------------------------------------------
City | SMYRNA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30080-2073
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-428-0414
-----------------------------------------------------
Fax | 770-428-0415
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OPTOMETRIST
-----------------------------------------------------
Name | DR. JANELLE LYNETTE DAVISON
-----------------------------------------------------
Credential | OD
-----------------------------------------------------
Telephone | 770-428-0414
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | OPT002350
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------