Provider Demographics
NPI:1013188952
Name:JOHN L. HENAHAN, OD, POC
Entity Type:Organization
Organization Name:JOHN L. HENAHAN, OD, POC
Other - Org Name:SPECTRUM EYECARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:L
Authorized Official - Last Name:HENAHAN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:770-487-0667
Mailing Address - Street 1:361 HIGHWAY 74 N
Mailing Address - Street 2:
Mailing Address - City:PEACHTREE CITY
Mailing Address - State:GA
Mailing Address - Zip Code:30269-1102
Mailing Address - Country:US
Mailing Address - Phone:770-487-0667
Mailing Address - Fax:770-487-0947
Practice Address - Street 1:361 HIGHWAY 74 N
Practice Address - Street 2:
Practice Address - City:PEACHTREE CITY
Practice Address - State:GA
Practice Address - Zip Code:30269-1102
Practice Address - Country:US
Practice Address - Phone:770-487-0667
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-19
Last Update Date:2016-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA511G410005Medicare PIN