Provider Demographics
NPI:1235412677
Name:CHAMBLESS EYE CARE LLC
Entity Type:Organization
Organization Name:CHAMBLESS EYE CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:H
Authorized Official - Last Name:CHAMBLESS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:478-405-7474
Mailing Address - Street 1:6501 PEAKE RD
Mailing Address - Street 2:BUILDING 1200
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31210-8042
Mailing Address - Country:US
Mailing Address - Phone:478-405-7474
Mailing Address - Fax:478-405-7475
Practice Address - Street 1:6501 PEAKE RD
Practice Address - Street 2:BUILDING 1200
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31210-8042
Practice Address - Country:US
Practice Address - Phone:478-405-7474
Practice Address - Fax:478-405-7475
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-22
Last Update Date:2011-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1097152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAU29629Medicare UPIN