=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295036556
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | T.J. VISION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/03/2010
-----------------------------------------------------
Last Update Date | 03/17/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5150 BUFORD HWY NE STE D120
-----------------------------------------------------
City | DORAVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30340-1170
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-234-9249
-----------------------------------------------------
Fax | 770-234-0306
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5150 BUFORD HWY NE STE D120
-----------------------------------------------------
City | DORAVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30340-1170
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-234-9249
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OPTOMETRIST
-----------------------------------------------------
Name | KEMENG WANG
-----------------------------------------------------
Credential | OD
-----------------------------------------------------
Telephone | 770-234-9249
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | INV-1-10-13161
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------