Provider Demographics
NPI:1811171689
Name:OPTICAL ASSOCIATES OF SOUTH GA LLO
Entity type:Organization
Organization Name:OPTICAL ASSOCIATES OF SOUTH GA LLO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
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:
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:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-28
Last Update Date:2007-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier