=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255984423
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MC DO OPTOMETRY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/17/2019
-----------------------------------------------------
Last Update Date | 12/07/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3615 CHARLES HARDY PKWY STE 200
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30157-9472
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-767-5548
-----------------------------------------------------
Fax | 770-505-5549
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 702 SW 8TH ST
-----------------------------------------------------
City | BENTONVILLE
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72716-0445
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MICHAEL DO
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 770-767-5548
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------