Provider Demographics
NPI:1588716997
Name:BALLENGER, LINDA REEVES (LDO)
Entity type:Individual
Prefix:
First Name:LINDA
Middle Name:REEVES
Last Name:BALLENGER
Suffix:
Gender:F
Credentials:LDO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10366 COMMERCE ST
Mailing Address - Street 2:
Mailing Address - City:SUMMERVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30747-1471
Mailing Address - Country:US
Mailing Address - Phone:706-857-7777
Mailing Address - Fax:706-857-7877
Practice Address - Street 1:10366 COMMERCE ST
Practice Address - Street 2:
Practice Address - City:SUMMERVILLE
Practice Address - State:GA
Practice Address - Zip Code:30747-1471
Practice Address - Country:US
Practice Address - Phone:706-857-7777
Practice Address - Fax:706-857-7877
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-17
Last Update Date:2008-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAGA963152W00000X
GA894156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
No152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAU22544Medicare UPIN
GA0168400001Medicare NSC
GA41ZCBDWMedicare PIN