=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780731950
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DR J HEAVEN, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/03/2007
-----------------------------------------------------
Last Update Date | 01/21/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5653 BUFORD HWY NE
-----------------------------------------------------
City | DORAVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30340-1200
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-396-2969
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5653 BUFORD HWY NE
-----------------------------------------------------
City | DORAVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30340-1200
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | JASON HEAVEN
-----------------------------------------------------
Credential | O.D.
-----------------------------------------------------
Telephone | 770-396-2969
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 1780
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------