Provider Demographics
NPI:1619547098
Name:YARBOROUGH, LINETTE ANICE (LDO)
Entity Type:Individual
Prefix:
First Name:LINETTE
Middle Name:ANICE
Last Name:YARBOROUGH
Suffix:
Gender:F
Credentials:LDO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8390 N HIGHWAY 27
Mailing Address - Street 2:
Mailing Address - City:ROCK SPRING
Mailing Address - State:GA
Mailing Address - Zip Code:30739-2103
Mailing Address - Country:US
Mailing Address - Phone:706-375-1720
Mailing Address - Fax:706-375-1729
Practice Address - Street 1:8390 N HIGHWAY 27
Practice Address - Street 2:
Practice Address - City:ROCK SPRING
Practice Address - State:GA
Practice Address - Zip Code:30739-2103
Practice Address - Country:US
Practice Address - Phone:706-375-1720
Practice Address - Fax:706-375-1729
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-29
Last Update Date:2021-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA152923602AMedicaid