Provider Demographics
NPI:1407094261
Name:OPTICAL SHOP AT ATHENS EYE ASSOCIATES, INC.
Entity Type:Organization
Organization Name:OPTICAL SHOP AT ATHENS EYE ASSOCIATES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:S
Authorized Official - Last Name:JACOBS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:706-549-7047
Mailing Address - Street 1:1080 VEND DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:BOGART
Mailing Address - State:GA
Mailing Address - Zip Code:30622-3051
Mailing Address - Country:US
Mailing Address - Phone:706-549-7047
Mailing Address - Fax:706-613-5395
Practice Address - Street 1:1080 VEND DR
Practice Address - Street 2:SUITE 100
Practice Address - City:BOGART
Practice Address - State:GA
Practice Address - Zip Code:30622-3051
Practice Address - Country:US
Practice Address - Phone:706-549-7047
Practice Address - Fax:706-613-5395
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ATHENS EYE ASSOCIATES, P.C.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-01-31
Last Update Date:2012-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA6325700001OtherHUMANA
GA6325700001OtherUNITED HEALTHCARE
GA6325700001Medicare NSC