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General NPI Number Information
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NPI Number | 1164945796
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Entity Type | Organization
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Legal Business Name | PARKSIDE OPTIQUE, LLC
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Dates
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Enumeration Date | 07/25/2017
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Last Update Date | 07/25/2017
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Provider Practice Location Address
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Address Line | 105 E MAIN ST STE 116
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City | WOODSTOCK
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State | GA
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Zip | 30188-5013
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Country | US
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Telephone | 770-485-7459
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Fax |
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Provider Business Mailing Address
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Address Line | 105 E MAIN ST STE 116
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City | WOODSTOCK
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State | GA
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Zip | 30188-5013
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER/DISPENSING OPTICIAN
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Name | LISA STONEBRAKER
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Credential | LDO
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Telephone | 770-485-7459
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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 |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 156FX1800X
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Taxonomy Name | Optician
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License Number |
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License Number State |
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