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General NPI Number Information
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NPI Number | 1649504424
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Entity Type | Organization
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Legal Business Name | EYE SHOP, P.C.
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Dates
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Enumeration Date | 09/25/2009
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Last Update Date | 09/25/2009
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Provider Practice Location Address
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Address Line | 3621 VININGS SLOPE SE SUITE 4150
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City | ATLANTA
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State | GA
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Zip | 30339-4107
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Country | US
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Telephone | 678-525-6737
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Fax |
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Provider Business Mailing Address
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Address Line | 400 W PEACHTREE ST NW UNIT 2315
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City | ATLANTA
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State | GA
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Zip | 30308-3536
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Country | US
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Telephone | 678-525-6737
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. DREW PROVOST
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Credential | O.D.
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Telephone | 678-525-6737
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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 | OPT 002244
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License Number State | GA
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