=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508531096
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MEL OPTICAL LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/16/2021
-----------------------------------------------------
Last Update Date | 08/17/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2735 HIGHWAY 54
-----------------------------------------------------
City | PEACHTREE CITY
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30269-1031
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-275-2020
-----------------------------------------------------
Fax | 561-828-8367
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1943 PLEASANT HILL RD
-----------------------------------------------------
City | DULUTH
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30096-4625
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CREDENTIALING MANAGER
-----------------------------------------------------
Name | DANIEL GARZA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 210-843-1393
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 332H00000X
-----------------------------------------------------
Taxonomy Name | Eyewear Supplier
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------