Provider Demographics
NPI:1760406300
Name:EYE1ST VISION & LASER, LLC
Entity Type:Organization
Organization Name:EYE1ST VISION & LASER, LLC
Other - Org Name:EYE1ST VISION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:ALFRED
Authorized Official - Last Name:STEWART
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:770-623-3931
Mailing Address - Street 1:10080 MEDLOCK BRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30097-2010
Mailing Address - Country:US
Mailing Address - Phone:770-623-3931
Mailing Address - Fax:770-623-3937
Practice Address - Street 1:10080 MEDLOCK BRIDGE RD
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30097-2010
Practice Address - Country:US
Practice Address - Phone:770-623-3931
Practice Address - Fax:770-623-3937
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-27
Last Update Date:2009-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT 001639152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA5680170001Medicare NSC
GAGRP6993Medicare ID - Type Unspecified