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General NPI Number Information
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NPI Number | 1184851800
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Entity Type | Organization
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Legal Business Name | TARA FOWLER OPTOMETRIC CORPORATION
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Dates
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Enumeration Date | 06/20/2009
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Last Update Date | 01/13/2020
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Provider Practice Location Address
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Address Line | 930 MARIETTA HWY STE 400
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City | ROSWELL
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State | GA
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Zip | 30075-6754
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Country | US
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Telephone | 770-998-3937
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Fax | 770-783-5066
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Provider Business Mailing Address
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Address Line | 930 MARIETTA HWY STE 400
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City | ROSWELL
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State | GA
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Zip | 30075-6754
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Country | US
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Telephone | 770-998-3937
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | TARA LEIGH FOWLER
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Credential | O.D.
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Telephone | 404-414-3238
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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 | OPT002415
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License Number State | GA
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