Provider Demographics
NPI:1457575680
Name:FASHION OPTIQUE EYEWEAR, INC
Entity Type:Organization
Organization Name:FASHION OPTIQUE EYEWEAR, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTICIAN
Authorized Official - Prefix:MS
Authorized Official - First Name:JUNE
Authorized Official - Middle Name:
Authorized Official - Last Name:MARTIN GRAHAM
Authorized Official - Suffix:
Authorized Official - Credentials:LDO
Authorized Official - Phone:404-244-8377
Mailing Address - Street 1:2851 CANDLER RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30034-1412
Mailing Address - Country:US
Mailing Address - Phone:404-244-8377
Mailing Address - Fax:404-244-0908
Practice Address - Street 1:2851 CANDLER RD
Practice Address - Street 2:SUITE 100
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30034-1412
Practice Address - Country:US
Practice Address - Phone:404-244-8377
Practice Address - Fax:404-244-0908
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALDO002123156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA=========OtherTAX ID #