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General NPI Number Information
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NPI Number | 1598374027
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Entity Type | Organization
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Legal Business Name | THE EYEDEAL SITE
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Dates
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Enumeration Date | 07/30/2020
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Last Update Date | 07/30/2020
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Provider Practice Location Address
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Address Line | 600 CARROLLTON VILLA RICA HWY
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City | VILLA RICA
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State | GA
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Zip | 30180-4969
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Country | US
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Telephone | 770-459-8733
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Fax | 770-459-8673
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Provider Business Mailing Address
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Address Line | 214 NELLIE TRCE SE
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City | MABLETON
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State | GA
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Zip | 30126-4451
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. PRESTON SMITH
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Credential | OD
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Telephone | 309-830-4590
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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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