Provider Demographics
NPI:1629784160
Name:MARIETTA EYE CLINIC, PA
Entity Type:Organization
Organization Name:MARIETTA EYE CLINIC, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:HENRY
Authorized Official - Middle Name:ELLIOTT
Authorized Official - Last Name:GATEHOUSE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-427-8111
Mailing Address - Street 1:895 CANTON RD NE
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30060-8934
Mailing Address - Country:US
Mailing Address - Phone:770-427-8111
Mailing Address - Fax:
Practice Address - Street 1:2860 RONALD REAGAN BLVD STE 210
Practice Address - Street 2:
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30041-6092
Practice Address - Country:US
Practice Address - Phone:770-427-8111
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MARIETTA EYE CLINIC, PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-01-27
Last Update Date:2023-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty