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General NPI Number Information
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NPI Number | 1851056865
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Entity Type | Organization
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Legal Business Name | BLAIRWOOD OPTICAL, LLC
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Dates
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Enumeration Date | 11/04/2021
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Last Update Date | 12/07/2021
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Provider Practice Location Address
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Address Line | 27184 US HIGHWAY 80 W
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City | PORTAL
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State | GA
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Zip | 30450-5247
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Country | US
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Telephone | 912-865-5300
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Fax | 912-865-5336
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Provider Business Mailing Address
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Address Line | PO BOX 710
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City | PORTAL
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State | GA
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Zip | 30450-0710
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Country | US
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Telephone | 912-865-5300
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Fax | 912-865-5336
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Authorized Official
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Title or Position | C0 OWNER
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Name | KRYSTAL LYNN PENLEY
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Credential | LDO2341
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Telephone | 912-865-5300
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 156FX1800X
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Taxonomy Name | Optician
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 332H00000X
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Taxonomy Name | Eyewear Supplier
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License Number |
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License Number State |
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