Provider Demographics
NPI:1124195631
Name:GEORGIA OPTOMETRY GROUP ASSOC. P.C.
Entity Type:Organization
Organization Name:GEORGIA OPTOMETRY GROUP ASSOC. P.C.
Other - Org Name:GEORGIA OPTOMETRY GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:T
Authorized Official - Last Name:PENCE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-394-2110
Mailing Address - Street 1:4480A CHAMBLEE DUNWOODY ROAD
Mailing Address - Street 2:
Mailing Address - City:DUNWOODY
Mailing Address - State:GA
Mailing Address - Zip Code:30338
Mailing Address - Country:US
Mailing Address - Phone:770-394-2110
Mailing Address - Fax:770-394-5630
Practice Address - Street 1:4480A CHAMBLEE DUNWOODY ROAD
Practice Address - Street 2:
Practice Address - City:DUNWOODY
Practice Address - State:GA
Practice Address - Zip Code:30338
Practice Address - Country:US
Practice Address - Phone:770-394-2110
Practice Address - Fax:770-394-5630
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-29
Last Update Date:2010-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP7409OtherGROUP I.D. NUMBER
GAGRP7409Medicare PIN