Provider Demographics
NPI:1619018355
Name:ADVANCED EYECARE, INC.
Entity Type:Organization
Organization Name:ADVANCED EYECARE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:
Authorized Official - Last Name:LOWE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:706-695-4676
Mailing Address - Street 1:911 N 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:CHATSWORTH
Mailing Address - State:GA
Mailing Address - Zip Code:30705-2115
Mailing Address - Country:US
Mailing Address - Phone:706-695-4676
Mailing Address - Fax:706-695-7364
Practice Address - Street 1:911 N 3RD AVE
Practice Address - Street 2:
Practice Address - City:CHATSWORTH
Practice Address - State:GA
Practice Address - Zip Code:30705-2115
Practice Address - Country:US
Practice Address - Phone:706-695-4676
Practice Address - Fax:706-695-7364
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-08
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT001580152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA=========OtherTAX ID NUMBER
GAU62969Medicare UPIN
GAU62350Medicare UPIN
GAGAA11212Medicare ID - Type Unspecified
GA1182970001Medicare NSC