Provider Demographics
NPI:1578613659
Name:VISION EYE GROUP OPTICAL
Entity Type:Organization
Organization Name:VISION EYE GROUP OPTICAL
Other - Org Name:FIRST LOOK OPTICIANS INC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:SIMONTON
Authorized Official - Last Name:PAYNE
Authorized Official - Suffix:
Authorized Official - Credentials:LDO
Authorized Official - Phone:478-743-2636
Mailing Address - Street 1:4050 RIVERSIDE DR
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31210-1805
Mailing Address - Country:US
Mailing Address - Phone:478-743-2636
Mailing Address - Fax:478-743-3235
Practice Address - Street 1:4050 RIVERSIDE DR
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31210-1805
Practice Address - Country:US
Practice Address - Phone:478-743-2636
Practice Address - Fax:478-743-3235
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-11
Last Update Date:2023-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA764156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00139961AMedicaid
GAE19961Medicare UPIN
GA0479110001Medicare ID - Type UnspecifiedMEDICARE PROVIDER
GAD46060Medicare UPIN
GA00139961AMedicaid
GAE86250Medicare UPIN