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General NPI Number Information
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NPI Number | 1326559659
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Entity Type | Organization
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Legal Business Name | QUYNH TA PA
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Dates
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Enumeration Date | 10/13/2017
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Last Update Date | 10/13/2017
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Provider Practice Location Address
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Address Line | 3333 BUFORD DR
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City | BUFORD
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State | GA
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Zip | 30519-4913
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Country | US
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Telephone | 770-932-1123
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Fax |
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Provider Business Mailing Address
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Address Line | 615 GRAN HERITAGE WAY
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City | DACULA
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State | GA
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Zip | 30019-7047
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Country | US
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Telephone | 407-227-3646
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Fax |
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Authorized Official
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Title or Position | OPTOMETRIST
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Name | QUYNH TA
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Credential | O.D
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Telephone | 407-227-3646
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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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