Provider Demographics
NPI:1881652196
Name:SUGARLOAF EYECARE, INC.
Entity Type:Organization
Organization Name:SUGARLOAF EYECARE, INC.
Other - Org Name:SUGARLOAF EYECARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:JONI
Authorized Official - Middle Name:L
Authorized Official - Last Name:REDDY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-495-0937
Mailing Address - Street 1:6555 SUGARLOAF PKWY
Mailing Address - Street 2:SUITE 303
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30097-4930
Mailing Address - Country:US
Mailing Address - Phone:770-495-0937
Mailing Address - Fax:678-417-6000
Practice Address - Street 1:6555 SUGARLOAF PKWY
Practice Address - Street 2:SUITE 303
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30097-4930
Practice Address - Country:US
Practice Address - Phone:770-495-0937
Practice Address - Fax:678-417-6000
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-03
Last Update Date:2009-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT001764152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA511G701045Medicare PIN