=====================================================
General NPI Number Information
=====================================================
NPI Number | 1487719084
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MODERN EYECARE OF MEDLOCK
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/25/2006
-----------------------------------------------------
Last Update Date | 09/11/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9700 MEDLOCK BRIDGE RD SUITE 182
-----------------------------------------------------
City | DULUTH
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30097-4411
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-205-1599
-----------------------------------------------------
Fax | 678-205-1632
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 190 BRIGHTMORE WAY
-----------------------------------------------------
City | ALPHARETTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30005-6773
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-205-1599
-----------------------------------------------------
Fax | 678-205-1632
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGING MEMEBER
-----------------------------------------------------
Name | GRACE K WOO
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 678-205-1599
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number | OPT002001
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | OPT002001
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------