Provider Demographics
NPI:1720217771
Name:ADVANCED EYE ASSOCIATES LLC
Entity Type:Organization
Organization Name:ADVANCED EYE ASSOCIATES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:ALFRED
Authorized Official - Middle Name:M
Authorized Official - Last Name:LONG
Authorized Official - Suffix:JR
Authorized Official - Credentials:OD
Authorized Official - Phone:770-422-8002
Mailing Address - Street 1:2645 DALLAS HWY SW
Mailing Address - Street 2:SUITE 100
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30064-2541
Mailing Address - Country:US
Mailing Address - Phone:770-422-8002
Mailing Address - Fax:770-422-4618
Practice Address - Street 1:2645 DALLAS HWY SW
Practice Address - Street 2:SUITE 100
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30064-2541
Practice Address - Country:US
Practice Address - Phone:770-422-8002
Practice Address - Fax:770-422-4618
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-13
Last Update Date:2016-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA152WOOOOOX152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact ManagementGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAU25346Medicare UPIN
GA41ZCCJJMedicare PIN
41ZCBCSMedicare PIN
U22423Medicare UPIN