Provider Demographics
NPI:1780850503
Name:CORDELE OPTICAL DISP., INC.
Entity Type:Organization
Organization Name:CORDELE OPTICAL DISP., INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTICIAN
Authorized Official - Prefix:
Authorized Official - First Name:DENAH
Authorized Official - Middle Name:
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:229-273-6678
Mailing Address - Street 1:PO BOX 70
Mailing Address - Street 2:
Mailing Address - City:CORDELE
Mailing Address - State:GA
Mailing Address - Zip Code:31010-0070
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:716 E 16TH AVE STE G
Practice Address - Street 2:
Practice Address - City:CORDELE
Practice Address - State:GA
Practice Address - Zip Code:31015-4517
Practice Address - Country:US
Practice Address - Phone:229-273-6678
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-01
Last Update Date:2008-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA2008000849332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA0878500001Medicare NSC