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General NPI Number Information
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NPI Number | 1922520501
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Entity Type | Individual
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Provider Name | HALEY PENROD OD
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Gender | Female
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Dates
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Enumeration Date | 07/14/2017
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Last Update Date | 10/06/2020
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Provider Practice Location Address
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Address Line | 131 UPPER RIVERDALE RD SW
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City | RIVERDALE
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State | GA
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Zip | 30274-2540
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Country | US
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Telephone | 770-994-9913
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Fax |
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Provider Business Mailing Address
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Address Line | 4056 IDLEVALE DR
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City | TUCKER
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State | GA
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Zip | 30084-7815
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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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 | 3045
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License Number State | GA
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Taxonomy #2
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Taxonomy Code | 152WV0400X
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Taxonomy Name | Vision Therapy Optometrist
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License Number | OPT003045
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License Number State | GA
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Taxonomy #3
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 2428
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License Number State | AZ
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