Provider Demographics
NPI:1184208290
Name:OLIVE EYECARE INC
Entity Type:Organization
Organization Name:OLIVE EYECARE INC
Other - Org Name:OLIVE EYECARE INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:TIFFANY
Authorized Official - Middle Name:D
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:225-747-7597
Mailing Address - Street 1:4480H S COBB DR SE STE 124
Mailing Address - Street 2:
Mailing Address - City:SMYRNA
Mailing Address - State:GA
Mailing Address - Zip Code:30080-6958
Mailing Address - Country:US
Mailing Address - Phone:770-743-6971
Mailing Address - Fax:
Practice Address - Street 1:2427 GRESHAM RD SE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30316-3709
Practice Address - Country:US
Practice Address - Phone:770-743-6971
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-05-06
Last Update Date:2021-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003126245AMedicaid