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General NPI Number Information
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NPI Number | 1417673591
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Entity Type | Organization
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Legal Business Name | SOUTHERN OCULAR PROSTHETICS, LLC
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Dates
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Enumeration Date | 10/19/2022
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Last Update Date | 10/19/2022
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Provider Practice Location Address
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Address Line | 2801 N DECATUR RD STE 130
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City | DECATUR
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State | GA
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Zip | 30033-6049
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Country | US
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Telephone | 470-296-2152
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Fax |
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Provider Business Mailing Address
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Address Line | 6065 ROSWELL RD STE 870
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City | SANDY SPRINGS
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State | GA
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Zip | 30328-4065
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Country | US
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Telephone | 559-940-1189
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | ANTONIO LOUIS ALCORTA I
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Credential | BCO BADO
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Telephone | 559-940-1189
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 156FX1700X
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Taxonomy Name | Ocularist
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License Number |
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License Number State |
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