Provider Demographics
NPI:1851763916
Name:MARY N, BRUNNER, LLC
Entity Type:Organization
Organization Name:MARY N, BRUNNER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARY
Authorized Official - Middle Name:N
Authorized Official - Last Name:BRUNNER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:404-296-2307
Mailing Address - Street 1:4765 MEMORIAL DR
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30032-1417
Mailing Address - Country:US
Mailing Address - Phone:404-296-2307
Mailing Address - Fax:
Practice Address - Street 1:4765 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30032-1417
Practice Address - Country:US
Practice Address - Phone:404-296-2307
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-28
Last Update Date:2015-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1170-T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty