Provider Demographics
NPI:1073897039
Name:SIGNATURE EYECARE, INC
Entity Type:Organization
Organization Name:SIGNATURE EYECARE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:CAMILLA
Authorized Official - Middle Name:
Authorized Official - Last Name:DONALD
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:404-519-7567
Mailing Address - Street 1:270 COBB PKWY S
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30060-9320
Mailing Address - Country:US
Mailing Address - Phone:404-519-7567
Mailing Address - Fax:678-418-1048
Practice Address - Street 1:10600 DAVIS DR
Practice Address - Street 2:
Practice Address - City:ALPHARETTA
Practice Address - State:GA
Practice Address - Zip Code:30009-4746
Practice Address - Country:US
Practice Address - Phone:770-992-6811
Practice Address - Fax:770-993-5205
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-07
Last Update Date:2011-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT002026152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003109625AMedicaid
MO95973Medicare UPIN