Provider Demographics
NPI:1760004584
Name:WEINER, KEVIN JOHN
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:JOHN
Last Name:WEINER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3301 BUCKEYE RD STE 700
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30341-4236
Mailing Address - Country:US
Mailing Address - Phone:404-634-4222
Mailing Address - Fax:404-634-1324
Practice Address - Street 1:3301 BUCKEYE RD STE 700
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30341-4236
Practice Address - Country:US
Practice Address - Phone:404-634-4222
Practice Address - Fax:404-634-1324
Is Sole Proprietor?:No
Enumeration Date:2020-05-14
Last Update Date:2020-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA156F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156F00000XEye and Vision Services ProvidersTechnician/Technologist