Provider Demographics
NPI:1477727964
Name:PREMIER OPHTHALMIC DISPENSARY LLC
Entity Type:Organization
Organization Name:PREMIER OPHTHALMIC DISPENSARY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:A
Authorized Official - Last Name:SZEKERESH
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:706-632-6989
Mailing Address - Street 1:11 MOUNTAIN ST
Mailing Address - Street 2:STE.3
Mailing Address - City:BLUE RIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30513-8586
Mailing Address - Country:US
Mailing Address - Phone:706-632-6989
Mailing Address - Fax:706-632-7478
Practice Address - Street 1:11 MOUNTAIN ST
Practice Address - Street 2:
Practice Address - City:BLUE RIDGE
Practice Address - State:GA
Practice Address - Zip Code:30513-8586
Practice Address - Country:US
Practice Address - Phone:706-632-6989
Practice Address - Fax:706-632-7478
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-16
Last Update Date:2013-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA049674332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA5666940001Medicare NSC