MEDICARE: SULICIA LEA JONES LDO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	156FX1800X	Optician	LDO001941	GA

General Provider Information

NPI Number	:	1033605217
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SULICIA LEA JONES LDO

Provider Business Mailing Address
First Line	:	37 JACK LN
Second Line	:
City	:	RINGGOLD
State	:	GA
Zip	:	30736-8250
Country	:	US
Telephone Number	:	423-619-4651
Fax Number	:

Provider Business Practice Location Address
First Line	:	1670 BATTLEFIELD PKWY
Second Line	:
City	:	FT OGLETHORPE
State	:	GA
Zip	:	30742-4046
Country	:	US
Telephone Number	:	423-619-4651
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/10/2018
Last Update Date	:	05/11/2019

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