Provider Demographics
NPI:1225199979
Name:SOUTHEASTERN EYE CLINICS PC
Entity Type:Organization
Organization Name:SOUTHEASTERN EYE CLINICS PC
Other - Org Name:PROFESSIONAL EYECARE OF STATESBORO
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:HORACE
Authorized Official - Middle Name:EDSEL
Authorized Official - Last Name:DEAL
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:912-764-5609
Mailing Address - Street 1:214 SAVANNAH AVE
Mailing Address - Street 2:
Mailing Address - City:STATESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30458-5165
Mailing Address - Country:US
Mailing Address - Phone:912-764-5609
Mailing Address - Fax:912-764-7786
Practice Address - Street 1:214 SAVANNAH AVE
Practice Address - Street 2:
Practice Address - City:STATESBORO
Practice Address - State:GA
Practice Address - Zip Code:30458-5165
Practice Address - Country:US
Practice Address - Phone:912-764-5609
Practice Address - Fax:912-764-7786
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-13
Last Update Date:2012-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPTO01603152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA202G701012Medicare PIN
GA3899110001Medicare NSC
GA41ZCDRMMedicare PIN