Provider Demographics
NPI:1821413006
Name:OPTIQUE SANDY SPRINGS, LLC
Entity Type:Organization
Organization Name:OPTIQUE SANDY SPRINGS, LLC
Other - Org Name:OPTIQUE ATLANTA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/SOLE MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:J
Authorized Official - Last Name:MORESI
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:678-939-2709
Mailing Address - Street 1:5940 ROSWELL RD
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30328-4908
Mailing Address - Country:US
Mailing Address - Phone:678-939-2709
Mailing Address - Fax:404-601-0795
Practice Address - Street 1:5940 ROSWELL RD
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30328-4908
Practice Address - Country:US
Practice Address - Phone:678-939-2709
Practice Address - Fax:404-601-0795
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-25
Last Update Date:2014-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT001083152W00000X
GAOPT002496152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty