Provider Demographics
NPI:1104849124
Name:GEORGIA VISION INSTITUTE
Entity type:Organization
Organization Name:GEORGIA VISION INSTITUTE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LAUREN
Authorized Official - Middle Name:WEST
Authorized Official - Last Name:YANCEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-834-1008
Mailing Address - Street 1:158 CLINIC AVE
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:GA
Mailing Address - Zip Code:30117-4414
Mailing Address - Country:US
Mailing Address - Phone:770-834-2020
Mailing Address - Fax:770-834-2531
Practice Address - Street 1:158 CLINIC AVE
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:GA
Practice Address - Zip Code:30117
Practice Address - Country:US
Practice Address - Phone:770-834-2020
Practice Address - Fax:770-834-2531
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-25
Last Update Date:2018-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA055000399AMedicaid
GA=========OtherTAX ID NUMBER
GA055000399AMedicaid