Provider Demographics
NPI:1043437486
Name:EYECARE ONE MARTINEZ LLC
Entity Type:Organization
Organization Name:EYECARE ONE MARTINEZ LLC
Other - Org Name:BROOME FAMILY EYECARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:WESLEY
Authorized Official - Last Name:BROOME
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:706-863-3030
Mailing Address - Street 1:510 NORTH BELAIR RD
Mailing Address - Street 2:
Mailing Address - City:EVANS
Mailing Address - State:GA
Mailing Address - Zip Code:30809
Mailing Address - Country:US
Mailing Address - Phone:706-863-3030
Mailing Address - Fax:706-863-0093
Practice Address - Street 1:510 NORTH BELAIR RD
Practice Address - Street 2:
Practice Address - City:EVANS
Practice Address - State:GA
Practice Address - Zip Code:30809
Practice Address - Country:US
Practice Address - Phone:706-863-3030
Practice Address - Fax:706-863-0093
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-19
Last Update Date:2009-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA848T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA52159903OtherBLUE CROSS BLUE SHIELD
GA52159903OtherBLUE CROSS BLUE SHIELD
GA5677700001Medicare NSC
GA41ZCGBRMedicare PIN