Provider Demographics
NPI:1669880936
Name:PEDIATRIC VISION DEVELOPMENT CENTER OF GWINNETT
Entity type:Organization
Organization Name:PEDIATRIC VISION DEVELOPMENT CENTER OF GWINNETT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:
Authorized Official - Last Name:ROUW
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:678-448-2854
Mailing Address - Street 1:2055 HAMILTON CREEK PKWY
Mailing Address - Street 2:STE 120
Mailing Address - City:DACULA
Mailing Address - State:GA
Mailing Address - Zip Code:30019-7204
Mailing Address - Country:US
Mailing Address - Phone:770-904-0979
Mailing Address - Fax:
Practice Address - Street 1:2055 HAMILTON CREEK PKWY
Practice Address - Street 2:STE 120
Practice Address - City:DACULA
Practice Address - State:GA
Practice Address - Zip Code:30019-7204
Practice Address - Country:US
Practice Address - Phone:770-904-0979
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-30
Last Update Date:2016-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA2355152WV0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152WV0400XEye and Vision Services ProvidersOptometristVision TherapyGroup - Single Specialty