=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700400843
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | E D GOODNIGHT LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/04/2020
-----------------------------------------------------
Last Update Date | 06/04/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6175 HARBOUR OVERLOOK
-----------------------------------------------------
City | ALPHARETTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30005-6901
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 713-851-1017
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6175 HARBOUR OVERLOOK
-----------------------------------------------------
City | ALPHARETTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30005-6901
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 713-851-1017
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | ELIZABETH GOODNIGHT
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 713-851-1017
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------