Provider Demographics
NPI:1063680833
Name:SURESIGHT AND ASSOCIATES L L C
Entity Type:Organization
Organization Name:SURESIGHT AND ASSOCIATES L L C
Other - Org Name:SURESIGHT EYECARE CANTON
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:JACKSON
Authorized Official - Last Name:WAYLAND
Authorized Official - Suffix:SR
Authorized Official - Credentials:OD
Authorized Official - Phone:770-345-5220
Mailing Address - Street 1:217 RIVERSTONE DR
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:GA
Mailing Address - Zip Code:30114-5256
Mailing Address - Country:US
Mailing Address - Phone:770-345-5220
Mailing Address - Fax:770-479-5011
Practice Address - Street 1:217 RIVERSTONE DR
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:GA
Practice Address - Zip Code:30114-5256
Practice Address - Country:US
Practice Address - Phone:770-345-5220
Practice Address - Fax:770-479-5011
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-14
Last Update Date:2009-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT0001624152W00000X
GAGA1769261QS0132X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No261QS0132XAmbulatory Health Care FacilitiesClinic/CenterOphthalmologic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAU85105Medicare UPIN
GAGRP4174Medicare PIN