Provider Demographics
NPI:1578902086
Name:NORCROSS EYE CENTER
Entity Type:Organization
Organization Name:NORCROSS EYE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GODWIN
Authorized Official - Middle Name:I
Authorized Official - Last Name:EKEKHOMEN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:404-735-9513
Mailing Address - Street 1:1560 INDIAN TRAIL LILBURN RD
Mailing Address - Street 2:SUITE 108
Mailing Address - City:NORCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:30093-2666
Mailing Address - Country:US
Mailing Address - Phone:404-735-9513
Mailing Address - Fax:
Practice Address - Street 1:1560 INDIAN TRAIL LILBURN RD
Practice Address - Street 2:SUITE 108
Practice Address - City:NORCROSS
Practice Address - State:GA
Practice Address - Zip Code:30093-2666
Practice Address - Country:US
Practice Address - Phone:404-735-9513
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-18
Last Update Date:2013-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT002372152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA354228415AMedicaid