Provider Demographics
NPI:1245393800
Name:MARIETTA EYE OPTICAL INC
Entity Type:Organization
Organization Name:MARIETTA EYE OPTICAL INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF OPTICAL
Authorized Official - Prefix:
Authorized Official - First Name:TIA
Authorized Official - Middle Name:
Authorized Official - Last Name:MCENTIRE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-784-0242
Mailing Address - Street 1:895 CANTON RD NE
Mailing Address - Street 2:BUILDING 100
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30060-8934
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8841 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:DOUGLASVILLE
Practice Address - State:GA
Practice Address - Zip Code:30134-2267
Practice Address - Country:US
Practice Address - Phone:770-577-2220
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-18
Last Update Date:2018-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies