Provider Demographics
NPI:1902005507
Name:SOUTHERN OPTOMETRICS, INC
Entity Type:Organization
Organization Name:SOUTHERN OPTOMETRICS, INC
Other - Org Name:BUCHANAN EYE CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DOCTOR/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:E
Authorized Official - Last Name:COOK
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:770-646-9100
Mailing Address - Street 1:402 COURTHOUSE SQUARE
Mailing Address - Street 2:
Mailing Address - City:BUCHANAN
Mailing Address - State:GA
Mailing Address - Zip Code:30113-0000
Mailing Address - Country:US
Mailing Address - Phone:770-646-9100
Mailing Address - Fax:770-646-0007
Practice Address - Street 1:402 COURTHOUSE SQUARE
Practice Address - Street 2:
Practice Address - City:BUCHANAN
Practice Address - State:GA
Practice Address - Zip Code:30113-0000
Practice Address - Country:US
Practice Address - Phone:770-646-9100
Practice Address - Fax:770-646-0007
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-13
Last Update Date:2009-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT002396152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA511G700067Medicare PIN