Provider Demographics
NPI:1851606271
Name:BAIN, KRISTY LEE (OD)
Entity Type:Individual
Prefix:DR
First Name:KRISTY
Middle Name:LEE
Last Name:BAIN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1407 LADSON CT
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30033-5393
Mailing Address - Country:US
Mailing Address - Phone:901-871-3350
Mailing Address - Fax:
Practice Address - Street 1:104 CHURCH ST
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30030-3325
Practice Address - Country:US
Practice Address - Phone:404-378-3694
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-10
Last Update Date:2010-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT002605152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist