=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770748287
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COLQUITT OPTICAL HOUSE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/23/2008
-----------------------------------------------------
Last Update Date | 07/23/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 22 1ST AVE SE
-----------------------------------------------------
City | MOULTRIE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31768-4750
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 229-890-2466
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 22 1ST AVE SE
-----------------------------------------------------
City | MOULTRIE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31768-4750
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 229-890-2466
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | LICENSED DISPENSING OPTICIAN/ OWNER
-----------------------------------------------------
Name | MS. GAIL STRICKLAND HILL
-----------------------------------------------------
Credential | LDO
-----------------------------------------------------
Telephone | 229-891-0525
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332H00000X
-----------------------------------------------------
Taxonomy Name | Eyewear Supplier
-----------------------------------------------------
License Number | GA805
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------