Provider Demographics
NPI:1295025674
Name:PAMELA CORRELL, LLC
Entity Type:Organization
Organization Name:PAMELA CORRELL, LLC
Other - Org Name:ONE WAY EYEGLASSES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:E
Authorized Official - Last Name:CORRELL
Authorized Official - Suffix:
Authorized Official - Credentials:LDO
Authorized Official - Phone:706-546-5285
Mailing Address - Street 1:2440 W BROAD ST STE 14
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30606-3428
Mailing Address - Country:US
Mailing Address - Phone:706-546-5285
Mailing Address - Fax:706-546-5494
Practice Address - Street 1:2440 W BROAD ST STE 14
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30606-3428
Practice Address - Country:US
Practice Address - Phone:706-546-5285
Practice Address - Fax:706-546-5494
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-19
Last Update Date:2011-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA001119332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA5946010001Medicare NSC