Provider Demographics
NPI:1932269107
Name:ICARE OF WEST GEORGIA
Entity Type:Organization
Organization Name:ICARE OF WEST GEORGIA
Other - Org Name:PEARLE VISION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:ALBERT
Authorized Official - Last Name:HOLLAND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-834-1008
Mailing Address - Street 1:1313 S PARK ST
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:GA
Mailing Address - Zip Code:30117-4433
Mailing Address - Country:US
Mailing Address - Phone:770-832-1457
Mailing Address - Fax:770-214-9693
Practice Address - Street 1:1313 S PARK ST
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:GA
Practice Address - Zip Code:30117-4433
Practice Address - Country:US
Practice Address - Phone:770-832-1457
Practice Address - Fax:770-214-9693
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-11
Last Update Date:2010-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA003633332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAIC-23266OtherSPECTERA PROVIDER NUMBER
GA=========OtherTAX ID NUMBER
GAGRP6064Medicare PIN
GA4936540001Medicare NSC