Provider Demographics
NPI:1396073862
Name:WILDWOOD EYE CARE LLC
Entity type:Organization
Organization Name:WILDWOOD EYE CARE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:GROSSWALD
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:770-952-6412
Mailing Address - Street 1:1545 POWERS FERRY RD
Mailing Address - Street 2:SUITE 240
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30067-9412
Mailing Address - Country:US
Mailing Address - Phone:770-952-6412
Mailing Address - Fax:770-953-2738
Practice Address - Street 1:1545 POWERS FERRY RD
Practice Address - Street 2:SUITE 240
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30067-9412
Practice Address - Country:US
Practice Address - Phone:770-952-6412
Practice Address - Fax:770-953-2738
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-22
Last Update Date:2024-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty