Provider Demographics
NPI:1063742245
Name:ROBERT S GENTILE ENTERPRISE PC
Entity type:Organization
Organization Name:ROBERT S GENTILE ENTERPRISE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:S
Authorized Official - Last Name:GENTILE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:912-283-7171
Mailing Address - Street 1:1701 BOULEVARD SQ
Mailing Address - Street 2:STE C
Mailing Address - City:WAYCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:31501-8021
Mailing Address - Country:US
Mailing Address - Phone:912-283-7171
Mailing Address - Fax:912-284-9183
Practice Address - Street 1:1701 BOULEVARD SQ
Practice Address - Street 2:STE C
Practice Address - City:WAYCROSS
Practice Address - State:GA
Practice Address - Zip Code:31501-8021
Practice Address - Country:US
Practice Address - Phone:912-283-7171
Practice Address - Fax:912-284-9183
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-11
Last Update Date:2010-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA115254692DMedicaid
GA115254692CMedicaid
GA202G419598Medicare PIN
GA115254692CMedicaid