Provider Demographics
NPI:1093086159
Name:ALFRED, PATRICK K (ABOC)
Entity Type:Individual
Prefix:
First Name:PATRICK
Middle Name:K
Last Name:ALFRED
Suffix:
Gender:M
Credentials:ABOC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 GEORGIA AVE E
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30214-1616
Mailing Address - Country:US
Mailing Address - Phone:770-719-9500
Mailing Address - Fax:
Practice Address - Street 1:120 GEORGIA AVE E
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214-1616
Practice Address - Country:US
Practice Address - Phone:770-719-9500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-21
Last Update Date:2012-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA083494156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician