Provider Demographics
NPI:1386200046
Name:TJ ROBERTS, LLC
Entity Type:Organization
Organization Name:TJ ROBERTS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TERRENCE
Authorized Official - Middle Name:
Authorized Official - Last Name:ROBERTS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:770-256-6073
Mailing Address - Street 1:524 MONARCH LAKE WAY
Mailing Address - Street 2:
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30281-7795
Mailing Address - Country:US
Mailing Address - Phone:770-256-6073
Mailing Address - Fax:
Practice Address - Street 1:539 GLYNN ST N
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214-1108
Practice Address - Country:US
Practice Address - Phone:678-817-7722
Practice Address - Fax:678-817-0067
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-17
Last Update Date:2019-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003208256AMedicaid