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General NPI Number Information
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NPI Number | 1811390826
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Entity Type | Organization
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Legal Business Name | SUPERIOR EYECARE OF MADISON INC
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Dates
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Enumeration Date | 10/04/2014
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Last Update Date | 12/22/2020
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Provider Practice Location Address
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Address Line | 1569 N EXPRESSWAY
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City | GRIFFIN
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State | GA
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Zip | 30223-1746
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Country | US
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Telephone | 770-233-6860
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Fax | 770-233-6825
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Provider Business Mailing Address
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Address Line | 125 PAVILION PKWY
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City | FAYETTEVILLE
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State | GA
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Zip | 30214-4098
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Country | US
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Telephone | 770-460-7894
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Fax | 770-719-4392
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Authorized Official
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Title or Position | OWNER/OPTOMETRIST
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Name | MALIQUE R PAYNE
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Credential | OD
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Telephone | 256-716-6955
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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 | R-227-TA-984
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License Number State | AL
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Taxonomy #2
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number |
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License Number State |
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