Provider Demographics
NPI:1417673591
Name:SOUTHERN OCULAR PROSTHETICS, LLC
Entity Type:Organization
Organization Name:SOUTHERN OCULAR PROSTHETICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ANTONIO
Authorized Official - Middle Name:LOUIS
Authorized Official - Last Name:ALCORTA
Authorized Official - Suffix:I
Authorized Official - Credentials:BCO BADO
Authorized Official - Phone:559-940-1189
Mailing Address - Street 1:6065 ROSWELL RD STE 870
Mailing Address - Street 2:
Mailing Address - City:SANDY SPRINGS
Mailing Address - State:GA
Mailing Address - Zip Code:30328-4065
Mailing Address - Country:US
Mailing Address - Phone:559-940-1189
Mailing Address - Fax:
Practice Address - Street 1:2801 N DECATUR RD STE 130
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30033-6049
Practice Address - Country:US
Practice Address - Phone:470-296-2152
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-10-19
Last Update Date:2022-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1700XEye and Vision Services ProvidersTechnician/TechnologistOcularistGroup - Single Specialty