Provider Demographics
NPI:1205127925
Name:EYEWATCH EYE CARE AND ASSOCIATES LLC
Entity type:Organization
Organization Name:EYEWATCH EYE CARE AND ASSOCIATES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ADEKUNLE
Authorized Official - Middle Name:EMMANUEL
Authorized Official - Last Name:OLUWADARE
Authorized Official - Suffix:
Authorized Official - Credentials:OD, MS
Authorized Official - Phone:610-800-1125
Mailing Address - Street 1:3592 HUDDLESTONE LN
Mailing Address - Street 2:
Mailing Address - City:BUFORD
Mailing Address - State:GA
Mailing Address - Zip Code:30519-4652
Mailing Address - Country:US
Mailing Address - Phone:678-288-3024
Mailing Address - Fax:678-889-9546
Practice Address - Street 1:1550 MALL OF GEORGIA BLVD
Practice Address - Street 2:
Practice Address - City:BUFORD
Practice Address - State:GA
Practice Address - Zip Code:30519-6551
Practice Address - Country:US
Practice Address - Phone:678-288-3024
Practice Address - Fax:678-482-1324
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-28
Last Update Date:2011-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT2345152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA511I410063Medicare PIN