Provider Demographics
NPI:1548811649
Name:MY SAVIOURS GRACE LLC
Entity type:Organization
Organization Name:MY SAVIOURS GRACE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:AMOS
Authorized Official - Middle Name:D
Authorized Official - Last Name:WASHINGTON
Authorized Official - Suffix:III
Authorized Official - Credentials:LDO
Authorized Official - Phone:678-682-5509
Mailing Address - Street 1:10269 INDUSTRIAL DR
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:GA
Mailing Address - Zip Code:30014
Mailing Address - Country:US
Mailing Address - Phone:678-682-5509
Mailing Address - Fax:
Practice Address - Street 1:10269 INDUSTRIAL BLVD NE
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:GA
Practice Address - Zip Code:30014-1485
Practice Address - Country:US
Practice Address - Phone:470-444-1474
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-09-20
Last Update Date:2019-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty