Provider Demographics
NPI:1255739637
Name:TOTAL VISION SUWANEE LLC
Entity type:Organization
Organization Name:TOTAL VISION SUWANEE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:PAULA
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:GORLIN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:770-271-0611
Mailing Address - Street 1:1000 PEACHTREE INDUSTRIAL BLVD
Mailing Address - Street 2:#14
Mailing Address - City:SUWANEE
Mailing Address - State:GA
Mailing Address - Zip Code:30024-6737
Mailing Address - Country:US
Mailing Address - Phone:770-271-0611
Mailing Address - Fax:770-271-5525
Practice Address - Street 1:1000 PEACHTREE INDUSTRIAL BLVD
Practice Address - Street 2:#14
Practice Address - City:SUWANEE
Practice Address - State:GA
Practice Address - Zip Code:30024-6737
Practice Address - Country:US
Practice Address - Phone:770-271-0611
Practice Address - Fax:770-271-5525
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-16
Last Update Date:2015-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT001130152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
U13230Medicare UPIN