Provider Demographics
NPI:1518693878
Name:BOLT EYE GROUP-CANTON LLC
Entity Type:Organization
Organization Name:BOLT EYE GROUP-CANTON LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:REIMBOLD
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:770-776-9000
Mailing Address - Street 1:4180 OLD MILTON
Mailing Address - Street 2:
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30005
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2060 CUMMING HWY STE 400
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:GA
Practice Address - Zip Code:30115-3793
Practice Address - Country:US
Practice Address - Phone:770-615-2007
Practice Address - Fax:770-615-6242
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-07-28
Last Update Date:2023-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty