Provider Demographics
NPI:1720566557
Name:B.SPECTACLED-SUWANEE
Entity Type:Organization
Organization Name:B.SPECTACLED-SUWANEE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:DYKEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-386-0295
Mailing Address - Street 1:991 PEACHTREE INDUSTRIAL BLVD STE 114
Mailing Address - Street 2:
Mailing Address - City:SUWANEE
Mailing Address - State:GA
Mailing Address - Zip Code:30024-4343
Mailing Address - Country:US
Mailing Address - Phone:770-904-0883
Mailing Address - Fax:678-765-0976
Practice Address - Street 1:991 PEACHTREE INDUSTRIAL BLVD STE 114
Practice Address - Street 2:
Practice Address - City:SUWANEE
Practice Address - State:GA
Practice Address - Zip Code:30024-4343
Practice Address - Country:US
Practice Address - Phone:770-904-0883
Practice Address - Fax:678-765-0976
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-03
Last Update Date:2022-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT002878152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty