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General NPI Number Information
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NPI Number | 1659308872
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Entity Type | Organization
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Legal Business Name | BLUE LASER GROUP
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Dates
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Enumeration Date | 06/26/2006
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Last Update Date | 03/07/2023
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Provider Practice Location Address
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Address Line | 1747 LANGFORD DRIVE BUILDING 400, SUITE 101
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City | BOGART
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State | GA
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Zip | 30622
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Country | US
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Telephone | 706-549-0005
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Fax | 706-850-3180
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Provider Business Mailing Address
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Address Line | 1747 LANGFORD DRIVE BUILDING 400, SUITE 101
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City | BOGART
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State | GA
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Zip | 30622
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Country | US
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Telephone | 706-549-0005
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Fax | 706-850-3180
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Authorized Official
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Title or Position | OPTHALMOLOGIST
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Name | RICHARD HOWARD BLUE
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Credential | M.D.
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Telephone | 706-549-0005
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207W00000X
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Taxonomy Name | Ophthalmology Physician
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License Number | 027348
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License Number State | GA
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