Provider Demographics
NPI:1073505053
Name:EYE SITE OF BUFORD, INC.
Entity Type:Organization
Organization Name:EYE SITE OF BUFORD, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:C FO
Authorized Official - Prefix:MR
Authorized Official - First Name:RAYMOND
Authorized Official - Middle Name:D
Authorized Official - Last Name:RUPURED
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:770-932-9656
Mailing Address - Street 1:4420 NELSON BROGDON BLVD
Mailing Address - Street 2:
Mailing Address - City:BUFORD
Mailing Address - State:GA
Mailing Address - Zip Code:30518-3477
Mailing Address - Country:US
Mailing Address - Phone:770-932-9656
Mailing Address - Fax:770-932-6606
Practice Address - Street 1:4420 NELSON BROGDON BLVD
Practice Address - Street 2:
Practice Address - City:BUFORD
Practice Address - State:GA
Practice Address - Zip Code:30518-3477
Practice Address - Country:US
Practice Address - Phone:770-932-9656
Practice Address - Fax:770-932-6606
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-16
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAGA1214332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier