Provider Demographics
NPI:1437279569
Name:EKHOS OPTICAL INC
Entity Type:Organization
Organization Name:EKHOS OPTICAL INC
Other - Org Name:BROOKWOOD EYECARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:
Authorized Official - Last Name:IMAFIDON
Authorized Official - Suffix:
Authorized Official - Credentials:OPT
Authorized Official - Phone:770-736-7774
Mailing Address - Street 1:2948 FIVE FORKS TRICKUM RD
Mailing Address - Street 2:SUITE C
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30044-5872
Mailing Address - Country:US
Mailing Address - Phone:770-736-7774
Mailing Address - Fax:
Practice Address - Street 1:2948 FIVE FORKS TRICKUM RD
Practice Address - Street 2:SUITE C
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30044-5872
Practice Address - Country:US
Practice Address - Phone:770-736-7774
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAGA0832152W00000X
156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Not Answered156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Multi-Specialty