Provider Demographics
NPI:1457578353
Name:PRIMARY VISION CARE CENTER, P.C.
Entity Type:Organization
Organization Name:PRIMARY VISION CARE CENTER, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:M
Authorized Official - Last Name:STILLIOND
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:770-229-1517
Mailing Address - Street 1:629 N EXPRESSWAY
Mailing Address - Street 2:D
Mailing Address - City:GRIFFIN
Mailing Address - State:GA
Mailing Address - Zip Code:30223-2083
Mailing Address - Country:US
Mailing Address - Phone:770-229-1517
Mailing Address - Fax:770-227-3877
Practice Address - Street 1:629 N EXPRESSWAY
Practice Address - Street 2:D
Practice Address - City:GRIFFIN
Practice Address - State:GA
Practice Address - Zip Code:30223-2083
Practice Address - Country:US
Practice Address - Phone:770-229-1517
Practice Address - Fax:770-227-3877
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT001126152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00416182CMedicaid
GAGRP6412Medicare ID - Type Unspecified