Provider Demographics
NPI:1790837706
Name:EAST GA REGIONAL EYE CENTER
Entity Type:Organization
Organization Name:EAST GA REGIONAL EYE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JACK
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:TENZEL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:912-764-6357
Mailing Address - Street 1:21 N ZETTEROWER AVE
Mailing Address - Street 2:
Mailing Address - City:STATESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30458-7142
Mailing Address - Country:US
Mailing Address - Phone:912-764-6357
Mailing Address - Fax:912-764-2192
Practice Address - Street 1:21 N ZETTEROWER AVE
Practice Address - Street 2:
Practice Address - City:STATESBORO
Practice Address - State:GA
Practice Address - Zip Code:30458-7142
Practice Address - Country:US
Practice Address - Phone:912-764-6357
Practice Address - Fax:912-764-2192
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-18
Last Update Date:2007-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA045642174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP7565Medicare ID - Type Unspecified