Provider Demographics
NPI:1558679191
Name:THEA ROSSI OD PC
Entity Type:Organization
Organization Name:THEA ROSSI OD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:THEA
Authorized Official - Middle Name:
Authorized Official - Last Name:ROSSI
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:404-323-0168
Mailing Address - Street 1:172 HAYNES ST SW UNIT 113
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30313-1377
Mailing Address - Country:US
Mailing Address - Phone:404-323-0168
Mailing Address - Fax:
Practice Address - Street 1:890 DAWSONVILLE HWY
Practice Address - Street 2:STE A
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501-2607
Practice Address - Country:US
Practice Address - Phone:770-532-4591
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-16
Last Update Date:2011-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT002127152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1104884873OtherNPI (INDIVIDUAL)