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General NPI Number Information
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NPI Number | 1104430537
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Entity Type | Organization
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Legal Business Name | HAPPY EYES LLC
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Dates
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Enumeration Date | 09/02/2020
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Last Update Date | 11/19/2020
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Provider Practice Location Address
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Address Line | 112A RIVERSTONE PKWY
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City | CANTON
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State | GA
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Zip | 30114-2448
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Country | US
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Telephone | 770-874-2020
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 4398
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City | CANTON
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State | GA
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Zip | 30114-0017
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Country | US
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Telephone | 770-874-2020
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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. RAFAEL GAMBA
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Credential | OD
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Telephone | 770-361-9481
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152WP0200X
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Taxonomy Name | Pediatric Optometrist
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number |
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License Number State |
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