Provider Demographics
NPI:1336326503
Name:STEPHENS COUNTY EYE CLINIC,INC
Entity Type:Organization
Organization Name:STEPHENS COUNTY EYE CLINIC,INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:RICK
Authorized Official - Last Name:VANDERHOEF
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:706-886-0111
Mailing Address - Street 1:1020 BIG A RD
Mailing Address - Street 2:
Mailing Address - City:TOCCOA
Mailing Address - State:GA
Mailing Address - Zip Code:30577-6010
Mailing Address - Country:US
Mailing Address - Phone:706-886-0111
Mailing Address - Fax:706-886-7680
Practice Address - Street 1:1020 BIG A RD
Practice Address - Street 2:
Practice Address - City:TOCCOA
Practice Address - State:GA
Practice Address - Zip Code:30577-6010
Practice Address - Country:US
Practice Address - Phone:706-886-0111
Practice Address - Fax:706-886-7680
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-30
Last Update Date:2008-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT001577152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000743003DMedicaid
GA180035168OtherRAILROAD MEDICARE
GA180035168OtherRAILROAD MEDICARE
GA41ZCDJMMedicare PIN
GA000743003DMedicaid