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General NPI Number Information
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NPI Number | 1356606719
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Entity Type | Organization
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Legal Business Name | INDEPENDENCE OPTICAL
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Dates
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Enumeration Date | 07/11/2012
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Last Update Date | 07/11/2012
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Provider Practice Location Address
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Address Line | 3230 HIGHWAY 42 STE E
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City | STOCKBRIDGE
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State | GA
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Zip | 30281-4667
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Country | US
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Telephone | 770-506-8845
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Fax | 770-506-8846
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Provider Business Mailing Address
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Address Line | 3230 HIGHWAY 42 STE E
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City | STOCKBRIDGE
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State | GA
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Zip | 30281-4667
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Country | US
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Telephone | 770-506-8845
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Fax | 770-506-8846
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Authorized Official
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Title or Position | VICE PRESIDENT
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Name | RANDY THOMAS TURLEY
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Credential | L.D.O
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Telephone | 770-506-8845
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 156FX1800X
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Taxonomy Name | Optician
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License Number | 2223
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License Number State | GA
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