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General NPI Number Information
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NPI Number | 1730548454
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Entity Type | Organization
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Legal Business Name | AUSTELL EYECARE INC
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Dates
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Enumeration Date | 02/23/2016
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Last Update Date | 02/23/2016
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Provider Practice Location Address
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Address Line | 1757 E WEST CONNECTOR SUITE 400
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City | AUSTELL
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State | GA
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Zip | 30106-1251
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Country | US
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Telephone | 770-941-2220
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Fax | 770-941-8481
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Provider Business Mailing Address
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Address Line | 1757 E WEST CONNECTOR SUITE 400
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City | AUSTELL
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State | GA
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Zip | 30106-1251
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Country | US
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Telephone | 770-941-2220
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Fax | 770-941-8481
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Authorized Official
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Title or Position | OWNERS
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Name | DR. JEREMY KOW
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Credential | O.D.
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Telephone | 770-941-2220
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | OPT 002648
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License Number State | GA
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