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General NPI Number Information
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NPI Number | 1164939112
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Entity Type | Organization
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Legal Business Name | EYE-CONIC OPTICAL, LLC
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Dates
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Enumeration Date | 12/29/2017
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Last Update Date | 12/29/2017
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Provider Practice Location Address
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Address Line | 1700 NORTHSIDE DR NW STE C3
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City | ATLANTA
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State | GA
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Zip | 30318-2696
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Country | US
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Telephone | 678-438-5612
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Fax |
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Provider Business Mailing Address
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Address Line | 1700 NORTHSIDE DR NW STE C3
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City | ATLANTA
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State | GA
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Zip | 30318-2696
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Country | US
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Telephone | 678-438-5612
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Fax |
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Authorized Official
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Title or Position | ORGANIZER
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Name | RICHARD CHARLES SCHLIEVERT
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Credential | OD
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Telephone | 678-438-5612
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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 | OPT002529
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License Number State | GA
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