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General NPI Number Information
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NPI Number | 1578210589
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Entity Type | Organization
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Legal Business Name | GWINNETT PEDIATRIC & ADULT EYE CENTER
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Dates
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Enumeration Date | 03/09/2022
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Last Update Date | 10/04/2023
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Provider Practice Location Address
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Address Line | 1300 PEACHTREE INDUSTRIAL BLVD STE 1206
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City | SUWANEE
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State | GA
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Zip | 30024-4550
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Country | US
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Telephone | 334-318-0713
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Fax |
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Provider Business Mailing Address
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Address Line | 1300 PEACHTREE INDUSTRIAL BLVD STE 1206
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City | SUWANEE
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State | GA
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Zip | 30024-4550
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Country | US
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Telephone | 770-783-2162
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Fax |
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Authorized Official
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Title or Position | OWNER/OD
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Name | SHUNDALE THOMAS MIXON
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Credential |
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Telephone | 770-783-2162
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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 |
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License Number State |
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