Provider Demographics
NPI:1588378632
Name:BOLT EYE GROUP - RIVERDALE, LLC
Entity type:Organization
Organization Name:BOLT EYE GROUP - RIVERDALE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:REIMBOLD
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:770-776-9000
Mailing Address - Street 1:4180 OLD MILTON PKWY STE 1D
Mailing Address - Street 2:
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30005-2408
Mailing Address - Country:US
Mailing Address - Phone:770-776-9000
Mailing Address - Fax:678-293-8499
Practice Address - Street 1:131 UPPER RIVERDALE RD SW
Practice Address - Street 2:
Practice Address - City:RIVERDALE
Practice Address - State:GA
Practice Address - Zip Code:30274-2540
Practice Address - Country:US
Practice Address - Phone:770-994-9913
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-01-12
Last Update Date:2023-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty