Provider Demographics
NPI:1326559659
Name:QUYNH TA PA
Entity Type:Organization
Organization Name:QUYNH TA PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:
Authorized Official - First Name:QUYNH
Authorized Official - Middle Name:
Authorized Official - Last Name:TA
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:407-227-3646
Mailing Address - Street 1:615 GRAN HERITAGE WAY
Mailing Address - Street 2:
Mailing Address - City:DACULA
Mailing Address - State:GA
Mailing Address - Zip Code:30019-7047
Mailing Address - Country:US
Mailing Address - Phone:407-227-3646
Mailing Address - Fax:
Practice Address - Street 1:3333 BUFORD DR
Practice Address - Street 2:
Practice Address - City:BUFORD
Practice Address - State:GA
Practice Address - Zip Code:30519-4913
Practice Address - Country:US
Practice Address - Phone:770-932-1123
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-13
Last Update Date:2017-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty