Provider Demographics
NPI:1780572933
Name:MARIETTA EYE OPTICAL INC
Entity type:Organization
Organization Name:MARIETTA EYE OPTICAL INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:
Authorized Official - Last Name:THACKSTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-427-8111
Mailing Address - Street 1:895 CANTON RD NE BLDG 100
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30060-8935
Mailing Address - Country:US
Mailing Address - Phone:770-427-8111
Mailing Address - Fax:770-499-1643
Practice Address - Street 1:4025 JOHNS CREEK PKWY
Practice Address - Street 2:
Practice Address - City:SUWANEE
Practice Address - State:GA
Practice Address - Zip Code:30024-5682
Practice Address - Country:US
Practice Address - Phone:770-427-8111
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MARIETTA EYE OPTICAL INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2025-06-26
Last Update Date:2025-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty