Provider Demographics
NPI:1154349041
Name:WINDER EYE CARE CENTER
Entity type:Organization
Organization Name:WINDER EYE CARE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:DR
Authorized Official - First Name:DARRELL
Authorized Official - Middle Name:A
Authorized Official - Last Name:SORAH
Authorized Official - Suffix:JR
Authorized Official - Credentials:OD
Authorized Official - Phone:770-867-2505
Mailing Address - Street 1:279 N BROAD ST
Mailing Address - Street 2:SUITE C
Mailing Address - City:WINDER
Mailing Address - State:GA
Mailing Address - Zip Code:30680-2583
Mailing Address - Country:US
Mailing Address - Phone:770-867-2505
Mailing Address - Fax:770-867-8668
Practice Address - Street 1:279 N BROAD ST
Practice Address - Street 2:SUITE C
Practice Address - City:WINDER
Practice Address - State:GA
Practice Address - Zip Code:30680-2583
Practice Address - Country:US
Practice Address - Phone:770-867-2505
Practice Address - Fax:770-867-8668
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-18
Last Update Date:2016-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA0590190001OtherDMERC SUPPLIER #
GA0590190001Medicare NSC