Provider Demographics
NPI:1912049693
Name:SWAINSBORO EYE CLINIC
Entity Type:Organization
Organization Name:SWAINSBORO EYE CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:HARLEY
Authorized Official - Middle Name:KEMP
Authorized Official - Last Name:JONES
Authorized Official - Suffix:JR
Authorized Official - Credentials:OD
Authorized Official - Phone:706-551-9553
Mailing Address - Street 1:803 FRENCH ST
Mailing Address - Street 2:
Mailing Address - City:SWAINSBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30401-5523
Mailing Address - Country:US
Mailing Address - Phone:706-551-9553
Mailing Address - Fax:
Practice Address - Street 1:342 W MAIN ST
Practice Address - Street 2:
Practice Address - City:SWAINSBORO
Practice Address - State:GA
Practice Address - Zip Code:30401-3104
Practice Address - Country:US
Practice Address - Phone:478-237-5909
Practice Address - Fax:478-237-3377
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-12
Last Update Date:2020-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
152W00000X
GAOPT 000827332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No332H00000XSuppliersEyewear SupplierGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00136804AMedicaid
GA1043222805OtherNPI
GA1043222805OtherNPI
GA00136804AMedicaid
GAUO5536Medicare UPIN