Provider Demographics
NPI:1063650422
Name:WOODSTOCK VISION CENTER, INC.
Entity Type:Organization
Organization Name:WOODSTOCK VISION CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:M
Authorized Official - Last Name:BLUM
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:678-457-0843
Mailing Address - Street 1:9801 HIGHWAY 92
Mailing Address - Street 2:SUITE 100
Mailing Address - City:WOODSTOCK
Mailing Address - State:GA
Mailing Address - Zip Code:30188-6453
Mailing Address - Country:US
Mailing Address - Phone:770-592-7400
Mailing Address - Fax:
Practice Address - Street 1:9801 HIGHWAY 92
Practice Address - Street 2:SUITE 100
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30188-6453
Practice Address - Country:US
Practice Address - Phone:770-592-7400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-22
Last Update Date:2009-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1072152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty