Provider Demographics
NPI:1114110574
Name:PRIMARY EYECARE
Entity Type:Organization
Organization Name:PRIMARY EYECARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BLLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LETA
Authorized Official - Middle Name:M
Authorized Official - Last Name:BIRD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:478-475-1600
Mailing Address - Street 1:3801 NORTHSDIE DR
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31201
Mailing Address - Country:US
Mailing Address - Phone:478-475-1600
Mailing Address - Fax:478-475-4160
Practice Address - Street 1:627 S HOUSTON LAKE RD
Practice Address - Street 2:SUITE 100
Practice Address - City:WARNER ROBINS
Practice Address - State:GA
Practice Address - Zip Code:31088-9077
Practice Address - Country:US
Practice Address - Phone:478-322-0009
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-20
Last Update Date:2008-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP4381Medicare PIN