Provider Demographics
NPI:1851056865
Name:BLAIRWOOD OPTICAL, LLC
Entity Type:Organization
Organization Name:BLAIRWOOD OPTICAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:C0 OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KRYSTAL
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:PENLEY
Authorized Official - Suffix:
Authorized Official - Credentials:LDO2341
Authorized Official - Phone:912-865-5300
Mailing Address - Street 1:PO BOX 710
Mailing Address - Street 2:
Mailing Address - City:PORTAL
Mailing Address - State:GA
Mailing Address - Zip Code:30450-0710
Mailing Address - Country:US
Mailing Address - Phone:912-865-5300
Mailing Address - Fax:912-865-5336
Practice Address - Street 1:27184 US HIGHWAY 80 W
Practice Address - Street 2:
Practice Address - City:PORTAL
Practice Address - State:GA
Practice Address - Zip Code:30450-5247
Practice Address - Country:US
Practice Address - Phone:912-865-5300
Practice Address - Fax:912-865-5336
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-11-04
Last Update Date:2021-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332H00000XSuppliersEyewear Supplier
No156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GALDO2341OtherLICENSED DISPENSING OPTICAN