=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811925977
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HABESHAM EYE CLINIC INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/29/2006
-----------------------------------------------------
Last Update Date | 02/20/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 35 PARKER LN
-----------------------------------------------------
City | RICHMOND HILL
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31324-3695
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-768-5198
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1614
-----------------------------------------------------
City | RICHMOND HILL
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31324-1614
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-768-5198
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. ERIC W COLEGROVE
-----------------------------------------------------
Credential | O.D.
-----------------------------------------------------
Telephone | 706-768-5198
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | OPT001763
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------