Provider Demographics
NPI:1811390826
Name:SUPERIOR EYECARE OF MADISON INC
Entity Type:Organization
Organization Name:SUPERIOR EYECARE OF MADISON INC
Other - Org Name:SUPERIOR EYECARE OF GRIFFIN
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER/OPTOMETRIST
Authorized Official - Prefix:
Authorized Official - First Name:MALIQUE
Authorized Official - Middle Name:R
Authorized Official - Last Name:PAYNE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:256-716-6955
Mailing Address - Street 1:125 PAVILION PKWY
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30214-4098
Mailing Address - Country:US
Mailing Address - Phone:770-460-7894
Mailing Address - Fax:770-719-4392
Practice Address - Street 1:1569 N EXPRESSWAY
Practice Address - Street 2:
Practice Address - City:GRIFFIN
Practice Address - State:GA
Practice Address - Zip Code:30223-1746
Practice Address - Country:US
Practice Address - Phone:770-233-6860
Practice Address - Fax:770-233-6825
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-04
Last Update Date:2020-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALR-227-TA-984152W00000X
152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003177763AMedicaid