Provider Demographics
NPI:1770129637
Name:WINDERMERE OPTIQUE LLC
Entity type:Organization
Organization Name:WINDERMERE OPTIQUE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:LOAN
Authorized Official - Middle Name:VO
Authorized Official - Last Name:UNSWORTH
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:770-574-6090
Mailing Address - Street 1:1788 SCOUTS WALK
Mailing Address - Street 2:
Mailing Address - City:DACULA
Mailing Address - State:GA
Mailing Address - Zip Code:30019-7817
Mailing Address - Country:US
Mailing Address - Phone:770-380-3501
Mailing Address - Fax:
Practice Address - Street 1:3130 MATHIS AIRPORT PKWY STE 308
Practice Address - Street 2:
Practice Address - City:SUWANEE
Practice Address - State:GA
Practice Address - Zip Code:30024-9132
Practice Address - Country:US
Practice Address - Phone:770-574-6090
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-11-25
Last Update Date:2020-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty