Provider Demographics
NPI:1912396276
Name:ECA OPTICAL, LLC
Entity Type:Organization
Organization Name:ECA OPTICAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:PERRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-351-2220
Mailing Address - Street 1:3225 CUMBERLAND BLVD SE
Mailing Address - Street 2:STE 900
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30339-6407
Mailing Address - Country:US
Mailing Address - Phone:404-351-2220
Mailing Address - Fax:
Practice Address - Street 1:340 BRANDYWINE BLVD
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214-1562
Practice Address - Country:US
Practice Address - Phone:770-460-4286
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EYE CONSULTANTS OF ATLANTA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-01-09
Last Update Date:2015-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALDO000890332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier