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General NPI Number Information
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NPI Number | 1407027683
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Entity Type | Organization
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Legal Business Name | MOBLEY RIVERDALE EYE CLINIC INC
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Dates
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Enumeration Date | 03/17/2008
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Last Update Date | 09/12/2011
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Provider Practice Location Address
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Address Line | 539 GLYNN ST N SUITE A
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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 | 539 GLYNN ST N SUITE A
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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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Authorized Official
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Title or Position | OWNER / OD
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Name | B. DEAN MOBLEY
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Credential | OD
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Telephone | 678-817-7722
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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 | 912T
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License Number State | GA
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