Provider Demographics
NPI:1730345265
Name:SENIOR-CARE VISION SERVICES GEORGIA PLLC
Entity type:Organization
Organization Name:SENIOR-CARE VISION SERVICES GEORGIA PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:C
Authorized Official - Last Name:WARDLAW
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:931-808-2129
Mailing Address - Street 1:PO BOX 7396
Mailing Address - Street 2:
Mailing Address - City:ROCKY MOUNT
Mailing Address - State:NC
Mailing Address - Zip Code:27804-0396
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1209 CLEVELAND RD
Practice Address - Street 2:#289
Practice Address - City:DALTON
Practice Address - State:GA
Practice Address - Zip Code:30721-8674
Practice Address - Country:US
Practice Address - Phone:877-766-7444
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-04
Last Update Date:2008-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA2374152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
T10683Medicare UPIN