Provider Demographics
NPI:1730510959
Name:JOSEPH OPTICAL
Entity type:Organization
Organization Name:JOSEPH OPTICAL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:
Authorized Official - Last Name:BACHMANN
Authorized Official - Suffix:
Authorized Official - Credentials:LDO
Authorized Official - Phone:770-479-0500
Mailing Address - Street 1:1455 RIVERSTONE PKWY SUITE 110
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:GA
Mailing Address - Zip Code:30114
Mailing Address - Country:US
Mailing Address - Phone:770-479-0500
Mailing Address - Fax:770-720-0104
Practice Address - Street 1:1455 RIVERSTONE PKWY SUITE 110
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:GA
Practice Address - Zip Code:30114
Practice Address - Country:US
Practice Address - Phone:770-479-0500
Practice Address - Fax:770-720-0104
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-13
Last Update Date:2013-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALDO001279332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier