=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912188996
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | OPTIWORLD VISION CENTER, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/19/2007
-----------------------------------------------------
Last Update Date | 11/19/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2801 CANDLER RD SUITE 66
-----------------------------------------------------
City | DECATUR
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30034-1423
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-244-8787
-----------------------------------------------------
Fax | 404-241-2248
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2801 CANDLER RD SUITE 66
-----------------------------------------------------
City | DECATUR
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30034-1423
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-244-8787
-----------------------------------------------------
Fax | 404-241-2248
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | DR. GEGE ODION
-----------------------------------------------------
Credential | O.D.
-----------------------------------------------------
Telephone | 404-244-8787
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332H00000X
-----------------------------------------------------
Taxonomy Name | Eyewear Supplier
-----------------------------------------------------
License Number | 1402
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------