Provider Demographics
NPI:1487719084
Name:MODERN EYECARE OF MEDLOCK
Entity type:Organization
Organization Name:MODERN EYECARE OF MEDLOCK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMEBER
Authorized Official - Prefix:
Authorized Official - First Name:GRACE
Authorized Official - Middle Name:K
Authorized Official - Last Name:WOO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-205-1599
Mailing Address - Street 1:190 BRIGHTMORE WAY
Mailing Address - Street 2:
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30005-6773
Mailing Address - Country:US
Mailing Address - Phone:678-205-1599
Mailing Address - Fax:678-205-1632
Practice Address - Street 1:9700 MEDLOCK BRIDGE RD
Practice Address - Street 2:SUITE 182
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30097-4411
Practice Address - Country:US
Practice Address - Phone:678-205-1599
Practice Address - Fax:678-205-1632
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT002001332B00000X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty
Not Answered152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA=========Medicaid
GA=========Medicare ID - Type UnspecifiedTIN NUMBER