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General NPI Number Information
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NPI Number | 1386200046
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Entity Type | Organization
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Legal Business Name | TJ ROBERTS, LLC
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Dates
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Enumeration Date | 05/17/2019
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Last Update Date | 05/17/2019
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Provider Practice Location Address
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Address Line | 539 GLYNN ST N
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City | FAYETTEVILLE
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State | GA
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Zip | 30214-1108
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Country | US
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Telephone | 678-817-7722
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Fax | 678-817-0067
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Provider Business Mailing Address
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Address Line | 524 MONARCH LAKE WAY
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City | STOCKBRIDGE
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State | GA
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Zip | 30281-7795
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Country | US
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Telephone | 770-256-6073
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. TERRENCE ROBERTS
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Credential | OD
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Telephone | 770-256-6073
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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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