Provider Demographics
NPI:1639775588
Name:EAST ATHENS FAMILY VISION, LLC
Entity Type:Organization
Organization Name:EAST ATHENS FAMILY VISION, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:DOUGLAS
Authorized Official - Last Name:SPRINGER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:706-543-3599
Mailing Address - Street 1:270 HAWTHORNE AVE
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30606-2881
Mailing Address - Country:US
Mailing Address - Phone:706-850-7101
Mailing Address - Fax:706-850-7089
Practice Address - Street 1:850 GAINES SCHOOL RD
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30605-3132
Practice Address - Country:US
Practice Address - Phone:706-850-7101
Practice Address - Fax:706-850-7089
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:RUSSELL D SPRINGER, P.C.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-12-07
Last Update Date:2022-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003257528AMedicaid
GA00772098AMedicaid