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General NPI Number Information
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NPI Number | 1457578353
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Entity Type | Organization
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Legal Business Name | PRIMARY VISION CARE CENTER, P.C.
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Dates
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Enumeration Date | 04/20/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 629 N EXPRESSWAY D
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City | GRIFFIN
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State | GA
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Zip | 30223-2083
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Country | US
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Telephone | 770-229-1517
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Fax | 770-227-3877
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Provider Business Mailing Address
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Address Line | 629 N EXPRESSWAY D
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City | GRIFFIN
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State | GA
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Zip | 30223-2083
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Country | US
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Telephone | 770-229-1517
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Fax | 770-227-3877
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. KEITH M STILLIOND
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Credential | O.D.
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Telephone | 770-229-1517
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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 | OPT001126
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License Number State | GA
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