Provider Demographics
NPI:1619409729
Name:LIL FIVE EYES LLC
Entity type:Organization
Organization Name:LIL FIVE EYES LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:COLAY
Authorized Official - Middle Name:ANQUANETTE
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-523-3937
Mailing Address - Street 1:484 MORELAND AVE NE STE D
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30307-3421
Mailing Address - Country:US
Mailing Address - Phone:404-523-3937
Mailing Address - Fax:404-688-3232
Practice Address - Street 1:484 MORELAND AVE NE
Practice Address - Street 2:D STE
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30307
Practice Address - Country:US
Practice Address - Phone:404-523-3937
Practice Address - Fax:404-688-3232
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-29
Last Update Date:2018-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAGA002600152W00000X
GA002600302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization
No152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1619409729Medicaid