Provider Demographics
NPI:1992042972
Name:OPTICA LATINA, LLC
Entity Type:Organization
Organization Name:OPTICA LATINA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LEONEL
Authorized Official - Middle Name:E
Authorized Official - Last Name:COELLO
Authorized Official - Suffix:
Authorized Official - Credentials:LDO
Authorized Official - Phone:770-815-1915
Mailing Address - Street 1:4485 LAWRENCEVILLE HWY NW
Mailing Address - Street 2:SUITE 206
Mailing Address - City:LILBURN
Mailing Address - State:GA
Mailing Address - Zip Code:30047-3669
Mailing Address - Country:US
Mailing Address - Phone:770-674-1712
Mailing Address - Fax:770-687-2921
Practice Address - Street 1:4485 LAWRENCEVILLE HWY NW
Practice Address - Street 2:SUITE 206
Practice Address - City:LILBURN
Practice Address - State:GA
Practice Address - Zip Code:30047-3669
Practice Address - Country:US
Practice Address - Phone:770-674-1712
Practice Address - Fax:770-687-2921
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-10
Last Update Date:2013-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT002681152W00000X
GALDO001948156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty