Provider Demographics
NPI:1376020495
Name:SONG BADARACCO EYECARE LLC
Entity type:Organization
Organization Name:SONG BADARACCO EYECARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OD
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:S
Authorized Official - Last Name:BADARACCO
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:215-688-7425
Mailing Address - Street 1:8415 MOOR PARK RUN
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30097-1695
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:870 INMAN VILLAGE PKWY NE STE 3
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30307-5523
Practice Address - Country:US
Practice Address - Phone:404-589-0822
Practice Address - Fax:404-589-4766
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-21
Last Update Date:2018-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT002861152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty