Provider Demographics
NPI:1407232515
Name:OPTIMIST LLC
Entity Type:Organization
Organization Name:OPTIMIST LLC
Other - Org Name:CLASSIC VISION CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MITAL
Authorized Official - Middle Name:
Authorized Official - Last Name:PATEL
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:678-560-8065
Mailing Address - Street 1:1615 RIDENOUR BLVD NW
Mailing Address - Street 2:#201
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30152-4463
Mailing Address - Country:US
Mailing Address - Phone:770-499-2020
Mailing Address - Fax:
Practice Address - Street 1:1615 RIDENOUR BLVD NW
Practice Address - Street 2:#201
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30152-4463
Practice Address - Country:US
Practice Address - Phone:770-499-2020
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MAPEYES LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-07-31
Last Update Date:2015-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty