Provider Demographics
NPI:1639340557
Name:PAUL J GLASS
Entity Type:Organization
Organization Name:PAUL J GLASS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECT OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:J
Authorized Official - Last Name:GLASS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-491-0105
Mailing Address - Street 1:2163 NORTHLAKE PKWY
Mailing Address - Street 2:STE 102
Mailing Address - City:TUCKER
Mailing Address - State:GA
Mailing Address - Zip Code:30084-4102
Mailing Address - Country:US
Mailing Address - Phone:770-491-0105
Mailing Address - Fax:770-934-6201
Practice Address - Street 1:2163 NORTHLAKE PKWY
Practice Address - Street 2:STE 102
Practice Address - City:TUCKER
Practice Address - State:GA
Practice Address - Zip Code:30084-4102
Practice Address - Country:US
Practice Address - Phone:770-491-0105
Practice Address - Fax:770-934-6201
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-19
Last Update Date:2008-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA026278332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
5646020001Medicare NSC