=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659780310
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KING FAMILY EYE CARE,LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/07/2014
-----------------------------------------------------
Last Update Date | 08/07/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1005 UNDERWOOD DR
-----------------------------------------------------
City | MACON
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31210-3332
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 478-477-2733
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1005 UNDERWOOD DR
-----------------------------------------------------
City | MACON
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31210-3332
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 478-477-2733
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER / CEO
-----------------------------------------------------
Name | DR. SEBORAH WILLIAMS KING
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 478-477-2733
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | OPT001942
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------