Provider Demographics
NPI:1598860801
Name:SOUTHERN EYE EXCELLENCE, LLC
Entity Type:Organization
Organization Name:SOUTHERN EYE EXCELLENCE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:LAWRENCE
Authorized Official - Middle Name:F
Authorized Official - Last Name:BRACK
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:770-987-0733
Mailing Address - Street 1:5900 HILLANDALE DRIVE
Mailing Address - Street 2:SUITE 345
Mailing Address - City:LITHONIA
Mailing Address - State:GA
Mailing Address - Zip Code:30058-6803
Mailing Address - Country:US
Mailing Address - Phone:770-987-0733
Mailing Address - Fax:770-987-3978
Practice Address - Street 1:5900 HILLANDALE DRIVE
Practice Address - Street 2:SUITE 345
Practice Address - City:LITHONIA
Practice Address - State:GA
Practice Address - Zip Code:30058-6803
Practice Address - Country:US
Practice Address - Phone:770-987-0733
Practice Address - Fax:770-987-3978
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA047403207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAH09713Medicare UPIN
GA18BDGHRMedicare ID - Type Unspecified