MEDICARE: SOUTHERN OPTOMETRICS, INC

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	OPT002396	GA

General Provider Information

NPI Number	:	1902005507
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHERN OPTOMETRICS, INC

Provider Business Mailing Address
First Line	:	402 COURTHOUSE SQUARE
Second Line	:
City	:	BUCHANAN
State	:	GA
Zip	:	30113-0000
Country	:	US
Telephone Number	:	770-646-9100
Fax Number	:	770-646-0007

Provider Business Practice Location Address
First Line	:	402 COURTHOUSE SQUARE
Second Line	:
City	:	BUCHANAN
State	:	GA
Zip	:	30113-0000
Country	:	US
Telephone Number	:	770-646-9100
Fax Number	:	770-646-0007

Authorized Official
Title or Position	:	DOCTOR/OWNER
Name	:	DR. CHRISTOPHER E COOK
Credential	:	O.D
Telephone Number	:	770-646-9100

Provider Enumeration Date	:	07/13/2007
Last Update Date	:	03/03/2009

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