Provider Demographics
NPI:1790802619
Name:POPHAM & LYNCH OPTICAL, INC.
Entity Type:Organization
Organization Name:POPHAM & LYNCH OPTICAL, INC.
Other - Org Name:GLYNN OPTICAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:BURNEA
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:JOUBERT
Authorized Official - Suffix:JR
Authorized Official - Credentials:LDO
Authorized Official - Phone:912-264-4015
Mailing Address - Street 1:2414A PARKWOOD DR
Mailing Address - Street 2:
Mailing Address - City:BRUNSWICK
Mailing Address - State:GA
Mailing Address - Zip Code:31520-4721
Mailing Address - Country:US
Mailing Address - Phone:912-264-4015
Mailing Address - Fax:
Practice Address - Street 1:2414A PARKWOOD DR
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:GA
Practice Address - Zip Code:31520-4721
Practice Address - Country:US
Practice Address - Phone:912-264-4015
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-24
Last Update Date:2008-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA905156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
0530260001Medicare NSC