Provider Demographics
NPI:1780993899
Name:OPTICAL ASSOCIATES OF SOUTH GA LLP
Entity type:Organization
Organization Name:OPTICAL ASSOCIATES OF SOUTH GA LLP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:CLIFFORD
Authorized Official - Middle Name:D
Authorized Official - Last Name:COURTENAY
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:229-247-4114
Mailing Address - Street 1:3024 N PATTERSON ST
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31602-1711
Mailing Address - Country:US
Mailing Address - Phone:229-247-4114
Mailing Address - Fax:229-245-9042
Practice Address - Street 1:3024 N PATTERSON ST
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-1711
Practice Address - Country:US
Practice Address - Phone:229-247-4114
Practice Address - Fax:229-245-9042
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-07
Last Update Date:2010-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT0001045152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty