Provider Demographics
NPI:1780875179
Name:LITHONIA FAMILY EYE CARE LLC
Entity type:Organization
Organization Name:LITHONIA FAMILY EYE CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANDRE
Authorized Official - Middle Name:TERRELL
Authorized Official - Last Name:LENOIR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:901-219-3989
Mailing Address - Street 1:5401 FAIRINGTON RD
Mailing Address - Street 2:
Mailing Address - City:LITHONIA
Mailing Address - State:GA
Mailing Address - Zip Code:30038-5113
Mailing Address - Country:US
Mailing Address - Phone:770-961-2020
Mailing Address - Fax:770-808-2787
Practice Address - Street 1:5401 FAIRINGTON RD
Practice Address - Street 2:
Practice Address - City:LITHONIA
Practice Address - State:GA
Practice Address - Zip Code:30038-5113
Practice Address - Country:US
Practice Address - Phone:770-808-2772
Practice Address - Fax:770-808-2787
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-09
Last Update Date:2016-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT002176152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA691118107AMedicaid
GA41ZVFWDMedicare PIN
GAGRP7236Medicare PIN
GA691118107AMedicaid