=====================================================
General NPI Number Information
=====================================================
NPI Number | 1851226369
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EYE TRAUMA SERVICES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/16/2026
-----------------------------------------------------
Last Update Date | 06/16/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1200 S COLUMBIA RD
-----------------------------------------------------
City | GRAND FORKS
-----------------------------------------------------
State | ND
-----------------------------------------------------
Zip | 58201-4036
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 470-514-0551
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3343 PEACHTREE RD NE STE 145
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30326-1427
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 470-514-0551
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | JOE BRADLEY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 470-514-0551
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207W00000X
-----------------------------------------------------
Taxonomy Name | Ophthalmology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------