=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548996754
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BOLT EYE GROUP-EAST COBB LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/29/2022
-----------------------------------------------------
Last Update Date | 08/16/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2255 SEWELL MILL RD #310
-----------------------------------------------------
City | MARIETTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30062
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-578-1900
-----------------------------------------------------
Fax | 770-578-2263
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4180 OLD MILTON PARKWAY
-----------------------------------------------------
City | ALPHARETTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30005
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BILLING SPECIALIST/OFFICE MANAGER
-----------------------------------------------------
Name | BARBARA WILLIAMS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 770-776-9000
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------