Provider Demographics
NPI:1992031074
Name:MIDTOWNE VISION CENTER, INC
Entity Type:Organization
Organization Name:MIDTOWNE VISION CENTER, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE ADMINISTRATOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MIRIAM
Authorized Official - Middle Name:D
Authorized Official - Last Name:TURNER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:478-803-0001
Mailing Address - Street 1:635 PIO NONO AVE
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31204-3531
Mailing Address - Country:US
Mailing Address - Phone:478-803-0001
Mailing Address - Fax:478-254-4997
Practice Address - Street 1:635 PIO NONO AVE
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31204-3531
Practice Address - Country:US
Practice Address - Phone:478-803-0001
Practice Address - Fax:478-254-4997
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-26
Last Update Date:2011-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1471152W00000X, 152WP0200X
GA002520152W00000X, 152WP0200X, 152WV0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
No152WP0200XEye and Vision Services ProvidersOptometristPediatricsGroup - Multi-Specialty
No152WV0400XEye and Vision Services ProvidersOptometristVision TherapyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000687981GMedicaid
GAU746489OtherUPIN
GAU746489OtherUPIN