Provider Demographics
NPI:1164772042
Name:PEACHTREE CORNERS EYE CLINIC
Entity Type:Organization
Organization Name:PEACHTREE CORNERS EYE CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:J
Authorized Official - Last Name:SHUSTER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:770-441-1211
Mailing Address - Street 1:4045 WETHERBURN WAY
Mailing Address - Street 2:SUITE 1
Mailing Address - City:NORCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:30092-4661
Mailing Address - Country:US
Mailing Address - Phone:770-441-1211
Mailing Address - Fax:770-448-9141
Practice Address - Street 1:4045 WETHERBURN WAY
Practice Address - Street 2:SUITE
Practice Address - City:NORCROSS
Practice Address - State:GA
Practice Address - Zip Code:30092-4661
Practice Address - Country:US
Practice Address - Phone:770-441-1211
Practice Address - Fax:770-448-9141
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PEACHTREE CORNERS EYE CLINIC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-09-18
Last Update Date:2012-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA001461T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAU26814Medicare UPIN