Provider Demographics
NPI:1093839474
Name:CHRISTIE EYE CARE
Entity Type:Organization
Organization Name:CHRISTIE EYE CARE
Other - Org Name:CHRISTIE EYE CARE
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DUDLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:CHRISTIE
Authorized Official - Suffix:JR
Authorized Official - Credentials:OD
Authorized Official - Phone:478-971-1500
Mailing Address - Street 1:198 S HOUSTON LAKE RD
Mailing Address - Street 2:STE B
Mailing Address - City:WARNER ROBINS
Mailing Address - State:GA
Mailing Address - Zip Code:31088-6473
Mailing Address - Country:US
Mailing Address - Phone:478-971-1500
Mailing Address - Fax:
Practice Address - Street 1:198 S HOUSTON LAKE RD
Practice Address - Street 2:STE B
Practice Address - City:WARNER ROBINS
Practice Address - State:GA
Practice Address - Zip Code:31088-6473
Practice Address - Country:US
Practice Address - Phone:478-971-1500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-19
Last Update Date:2014-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00055767FMedicaid
GA00055767GMedicaid
GA00055767EMedicaid
GAGRP6330Medicare ID - Type Unspecified
GA00055767GMedicaid
GA0300780002Medicare NSC
GAU20071Medicare UPIN
GA1447322151Medicare PIN
GA1255320859Medicare PIN