Provider Demographics
NPI:1386612703
Name:SISTAR EYECARE ASSOCIATES
Entity type:Organization
Organization Name:SISTAR EYECARE ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:LEON
Authorized Official - Last Name:SISTER
Authorized Official - Suffix:JR
Authorized Official - Credentials:OD
Authorized Official - Phone:912-285-0020
Mailing Address - Street 1:PO BOX 1465
Mailing Address - Street 2:545 KNIGHT AVE
Mailing Address - City:WAYCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:31502-1465
Mailing Address - Country:US
Mailing Address - Phone:912-285-0020
Mailing Address - Fax:912-285-8222
Practice Address - Street 1:545 KNIGHT AVE
Practice Address - Street 2:
Practice Address - City:WAYCROSS
Practice Address - State:GA
Practice Address - Zip Code:31501-3354
Practice Address - Country:US
Practice Address - Phone:912-285-0020
Practice Address - Fax:912-285-8222
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-10
Last Update Date:2008-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA919T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00204663DMedicaid
GA52194992OtherBCBS
U25605Medicare UPIN
GA1206740001Medicare NSC
GA52194992OtherBCBS