Provider Demographics
NPI:1053472308
Name:MIRAFLORES EYECARE, P.C.
Entity Type:Organization
Organization Name:MIRAFLORES EYECARE, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:MIRAFLORES
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:770-612-1372
Mailing Address - Street 1:2783 BENTLEY PL SE
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30067-5324
Mailing Address - Country:US
Mailing Address - Phone:770-612-1372
Mailing Address - Fax:
Practice Address - Street 1:6995 CONCOURSE PKWY
Practice Address - Street 2:
Practice Address - City:DOUGLASVILLE
Practice Address - State:GA
Practice Address - Zip Code:30134-4551
Practice Address - Country:US
Practice Address - Phone:770-489-2622
Practice Address - Fax:770-489-8318
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA2030152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty