Provider Demographics
NPI:1508089277
Name:OPTICAL BOUTIQUE
Entity Type:Organization
Organization Name:OPTICAL BOUTIQUE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:CARLIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-979-2020
Mailing Address - Street 1:2347 LENORA CHURCH RD
Mailing Address - Street 2:
Mailing Address - City:SNELLVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30078-3232
Mailing Address - Country:US
Mailing Address - Phone:770-979-2020
Mailing Address - Fax:
Practice Address - Street 1:2347 LENORA CHURCH RD
Practice Address - Street 2:
Practice Address - City:SNELLVILLE
Practice Address - State:GA
Practice Address - Zip Code:30078-3232
Practice Address - Country:US
Practice Address - Phone:770-979-2020
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-11
Last Update Date:2009-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1190790001Medicare NSC