Provider Demographics
NPI:1740420983
Name:HENRY VISION CENTER LLC
Entity Type:Organization
Organization Name:HENRY VISION CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/OPTOMETRIST
Authorized Official - Prefix:
Authorized Official - First Name:NICKSON
Authorized Official - Middle Name:
Authorized Official - Last Name:HENRY
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:770-474-5617
Mailing Address - Street 1:3564 HIGHWAY 138 SE
Mailing Address - Street 2:
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30281-4170
Mailing Address - Country:US
Mailing Address - Phone:770-474-5617
Mailing Address - Fax:770-474-6576
Practice Address - Street 1:3564 HIGHWAY 138 SE
Practice Address - Street 2:
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281-4170
Practice Address - Country:US
Practice Address - Phone:770-474-5617
Practice Address - Fax:770-474-6576
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-28
Last Update Date:2014-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA202G708531Medicare PIN
GAV12058Medicare UPIN
GADR4313Medicare PIN