=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700166394
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THE EYES HAVE IT, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/26/2011
-----------------------------------------------------
Last Update Date | 08/26/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6525 TARA BLVD SUITE 134
-----------------------------------------------------
City | JONESBORO
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30236-1227
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-369-8676
-----------------------------------------------------
Fax | 678-369-8676
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5174 HICKORY CIR
-----------------------------------------------------
City | ELLENWOOD
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30294-3689
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax | 678-369-8676
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/OPTOMETRIST
-----------------------------------------------------
Name | DR. LACHIONTE CULPEPPER
-----------------------------------------------------
Credential | D.O.
-----------------------------------------------------
Telephone | 678-572-5705
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | OPT002500
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------