Provider Demographics
NPI:1346390895
Name:OPTICAL ILLUSIONS, PC
Entity type:Organization
Organization Name:OPTICAL ILLUSIONS, PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:IAN
Authorized Official - Middle Name:
Authorized Official - Last Name:BUCHLI
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:912-729-6111
Mailing Address - Street 1:775 C KINGSBAY ROAD
Mailing Address - Street 2:
Mailing Address - City:ST MARYS
Mailing Address - State:GA
Mailing Address - Zip Code:31558
Mailing Address - Country:US
Mailing Address - Phone:912-729-6111
Mailing Address - Fax:912-729-8595
Practice Address - Street 1:775 C KINGSBAY ROAD
Practice Address - Street 2:
Practice Address - City:ST MARYS
Practice Address - State:GA
Practice Address - Zip Code:31558
Practice Address - Country:US
Practice Address - Phone:912-729-6111
Practice Address - Fax:912-729-8595
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-10
Last Update Date:2009-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT0001798152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000954291AMedicaid
GAU74150Medicare UPIN