Provider Demographics
NPI:1487641858
Name:NORTHEAST GEORGIA VISION CARE LLC
Entity Type:Organization
Organization Name:NORTHEAST GEORGIA VISION CARE LLC
Other - Org Name:KING VISION CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:HOLTON
Authorized Official - Middle Name:S
Authorized Official - Last Name:KING
Authorized Official - Suffix:JR
Authorized Official - Credentials:OD
Authorized Official - Phone:706-776-2020
Mailing Address - Street 1:118 VISION DR
Mailing Address - Street 2:
Mailing Address - City:CORNELIA
Mailing Address - State:GA
Mailing Address - Zip Code:30531-5737
Mailing Address - Country:US
Mailing Address - Phone:706-776-6311
Mailing Address - Fax:706-776-7243
Practice Address - Street 1:118 VISION DR
Practice Address - Street 2:
Practice Address - City:CORNELIA
Practice Address - State:GA
Practice Address - Zip Code:30531-5737
Practice Address - Country:US
Practice Address - Phone:706-776-6311
Practice Address - Fax:706-776-7243
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-30
Last Update Date:2023-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1106152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00515545BMedicaid
GRP8049Medicare PIN
GA00515545BMedicaid