MEDICARE: EYE SHOP, P.C.

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	152W00000X	Optometrist	OPT 002244	GA

General Provider Information

NPI Number	:	1649504424
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EYE SHOP, P.C.

Provider Business Mailing Address
First Line	:	400 W PEACHTREE ST NW
Second Line	:	UNIT 2315
City	:	ATLANTA
State	:	GA
Zip	:	30308-3536
Country	:	US
Telephone Number	:	678-525-6737
Fax Number	:

Provider Business Practice Location Address
First Line	:	3621 VININGS SLOPE SE
Second Line	:	SUITE 4150
City	:	ATLANTA
State	:	GA
Zip	:	30339-4107
Country	:	US
Telephone Number	:	678-525-6737
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. DREW PROVOST
Credential	:	O.D.
Telephone Number	:	678-525-6737

Provider Enumeration Date	:	09/25/2009
Last Update Date	:	09/25/2009

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Directions to “EYE SHOP, P.C. ” Practice Location

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