Provider Demographics
NPI:1073772828
Name:MOUNTAIN EYE CLINIC, PC
Entity Type:Organization
Organization Name:MOUNTAIN EYE CLINIC, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:G
Authorized Official - Last Name:JABALEY
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:706-864-8635
Mailing Address - Street 1:431 GROVE ST N
Mailing Address - Street 2:SUITE C
Mailing Address - City:DAHLONEGA
Mailing Address - State:GA
Mailing Address - Zip Code:30533-0437
Mailing Address - Country:US
Mailing Address - Phone:706-864-8635
Mailing Address - Fax:706-864-2441
Practice Address - Street 1:431 GROVE ST N
Practice Address - Street 2:SUITE C
Practice Address - City:DAHLONEGA
Practice Address - State:GA
Practice Address - Zip Code:30533-0437
Practice Address - Country:US
Practice Address - Phone:706-864-8635
Practice Address - Fax:706-864-2441
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-06
Last Update Date:2013-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT001389152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000712269AMedicaid
GA000712269AMedicaid
GAGRP6646Medicare PIN