Provider Demographics
NPI:1346357928
Name:CARROLLTON EYE CLINIC, PC
Entity Type:Organization
Organization Name:CARROLLTON EYE CLINIC, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANGIE
Authorized Official - Middle Name:
Authorized Official - Last Name:BRADLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-834-1008
Mailing Address - Street 1:158 CLINIC AVE
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:GA
Mailing Address - Zip Code:30117-4414
Mailing Address - Country:US
Mailing Address - Phone:770-834-1008
Mailing Address - Fax:770-834-2531
Practice Address - Street 1:158 CLINIC AVE
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:GA
Practice Address - Zip Code:30117-4414
Practice Address - Country:US
Practice Address - Phone:770-834-1008
Practice Address - Fax:770-834-2531
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-23
Last Update Date:2009-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA300022259AMedicaid
GA300022259AMedicaid