Provider Demographics
NPI:1356606719
Name:INDEPENDENCE OPTICAL
Entity type:Organization
Organization Name:INDEPENDENCE OPTICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RANDY
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:TURLEY
Authorized Official - Suffix:
Authorized Official - Credentials:LDO
Authorized Official - Phone:770-506-8845
Mailing Address - Street 1:3230 HIGHWAY 42 STE E
Mailing Address - Street 2:
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30281-4667
Mailing Address - Country:US
Mailing Address - Phone:770-506-8845
Mailing Address - Fax:770-506-8846
Practice Address - Street 1:3230 HIGHWAY 42 STE E
Practice Address - Street 2:
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281-4667
Practice Address - Country:US
Practice Address - Phone:770-506-8845
Practice Address - Fax:770-506-8846
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-11
Last Update Date:2012-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA2223156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Multi-Specialty