Provider Demographics
NPI:1164945796
Name:PARKSIDE OPTIQUE, LLC
Entity Type:Organization
Organization Name:PARKSIDE OPTIQUE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DISPENSING OPTICIAN
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:STONEBRAKER
Authorized Official - Suffix:
Authorized Official - Credentials:LDO
Authorized Official - Phone:770-485-7459
Mailing Address - Street 1:105 E MAIN ST STE 116
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:GA
Mailing Address - Zip Code:30188-5013
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:105 E MAIN ST STE 116
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30188-5013
Practice Address - Country:US
Practice Address - Phone:770-485-7459
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-25
Last Update Date:2017-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Multi-Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty