=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508495474
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EAGLE VIEW EYE CARE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/03/2020
-----------------------------------------------------
Last Update Date | 10/07/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4008 MUNDY MILL RD
-----------------------------------------------------
City | OAKWOOD
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30566-2807
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-576-7238
-----------------------------------------------------
Fax | 706-640-3877
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4008 MUNDY MILL RD
-----------------------------------------------------
City | OAKWOOD
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30566-2807
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-576-7283
-----------------------------------------------------
Fax | 706-640-3877
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/MEMBER
-----------------------------------------------------
Name | DR. DEREK ALAN BLACK
-----------------------------------------------------
Credential | OD
-----------------------------------------------------
Telephone | 404-697-2850
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------