=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669709473
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GEORGIA EYE SERVICES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/16/2009
-----------------------------------------------------
Last Update Date | 11/16/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3999 AUSTELL RD
-----------------------------------------------------
City | AUSTELL
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30106-1100
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-941-2323
-----------------------------------------------------
Fax | 770-941-9220
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3999 AUSTELL RD
-----------------------------------------------------
City | AUSTELL
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30106-1100
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-941-2323
-----------------------------------------------------
Fax | 770-941-9220
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | ROBERT WESLEY MOBLEY
-----------------------------------------------------
Credential | O,D,
-----------------------------------------------------
Telephone | 770-941-2323
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | OPT002200
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------