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General NPI Number Information
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NPI Number | 1164695045
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Entity Type | Organization
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Legal Business Name | VICTORY EYECARE LLC
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Dates
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Enumeration Date | 04/11/2008
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Last Update Date | 04/11/2008
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Provider Practice Location Address
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Address Line | 1342 AUBURN RD
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City | DACULA
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State | GA
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Zip | 30019-1140
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Country | US
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Telephone | 678-482-1324
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Fax |
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Provider Business Mailing Address
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Address Line | 3592 HUDDLESTONE LN
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City | BUFORD
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State | GA
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Zip | 30519-4652
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Country | US
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Telephone | 678-482-1324
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Fax |
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Authorized Official
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Title or Position | MANAGING PARTNER
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Name | DR. KUNLE EMMANUEL OLUWADARE
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Credential | M.S., O.D.
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Telephone | 678-482-1324
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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 | OPT002345
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License Number State | GA
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