Provider Demographics
NPI:1861601452
Name:THE OPTICAL CENTER PC
Entity type:Organization
Organization Name:THE OPTICAL CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTICIAN
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:
Authorized Official - Last Name:BURNETT
Authorized Official - Suffix:SR
Authorized Official - Credentials:LDO
Authorized Official - Phone:404-918-1916
Mailing Address - Street 1:6945 DEER CREEK TRCE
Mailing Address - Street 2:
Mailing Address - City:STONE MOUNTAIN
Mailing Address - State:GA
Mailing Address - Zip Code:30087-5477
Mailing Address - Country:US
Mailing Address - Phone:404-918-1916
Mailing Address - Fax:678-267-2865
Practice Address - Street 1:6945 DEER CREEK TRCE
Practice Address - Street 2:
Practice Address - City:STONE MOUNTAIN
Practice Address - State:GA
Practice Address - Zip Code:30087-5477
Practice Address - Country:US
Practice Address - Phone:404-918-1916
Practice Address - Fax:678-267-2865
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-21
Last Update Date:2010-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA202G417382Medicare PIN