MEDICARE: MARY N, BRUNNER, LLC

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	1170-T	GA

General Provider Information

NPI Number	:	1851763916
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MARY N, BRUNNER, LLC

Provider Business Mailing Address
First Line	:	4765 MEMORIAL DR
Second Line	:
City	:	DECATUR
State	:	GA
Zip	:	30032-1417
Country	:	US
Telephone Number	:	404-296-2307
Fax Number	:

Provider Business Practice Location Address
First Line	:	4765 MEMORIAL DR
Second Line	:
City	:	DECATUR
State	:	GA
Zip	:	30032-1417
Country	:	US
Telephone Number	:	404-296-2307
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. MARY N BRUNNER
Credential	:	O.D.
Telephone Number	:	404-296-2307

Provider Enumeration Date	:	10/28/2015
Last Update Date	:	10/28/2015

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