Provider Demographics
NPI:1588788293
Name:K D M VISION CENTER INC
Entity type:Organization
Organization Name:K D M VISION CENTER INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNERPRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:KIRK
Authorized Official - Middle Name:D
Authorized Official - Last Name:MALERBI
Authorized Official - Suffix:
Authorized Official - Credentials:LDO
Authorized Official - Phone:706-226-2722
Mailing Address - Street 1:4413 ARBOR TRL
Mailing Address - Street 2:
Mailing Address - City:COHUTTA
Mailing Address - State:GA
Mailing Address - Zip Code:30710-9323
Mailing Address - Country:US
Mailing Address - Phone:706-694-2020
Mailing Address - Fax:206-275-6114
Practice Address - Street 1:2150 E WALNUT AVE
Practice Address - Street 2:STE 10
Practice Address - City:DALTON
Practice Address - State:GA
Practice Address - Zip Code:30721-4500
Practice Address - Country:US
Practice Address - Phone:706-226-2722
Practice Address - Fax:706-275-6114
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-19
Last Update Date:2013-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1838152W00000X
GAGA1605156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGA1605OtherLISCENSED DISPENSING OPTI
GAU12958Medicare UPIN