Provider Demographics
NPI:1891910618
Name:FAYETTE MEDICAL CLINIC OPTICAL SHOP
Entity type:Organization
Organization Name:FAYETTE MEDICAL CLINIC OPTICAL SHOP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:RICK
Authorized Official - Middle Name:
Authorized Official - Last Name:RODECKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-351-2220
Mailing Address - Street 1:101 YORKTOWN DR STE 225
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30214-1568
Mailing Address - Country:US
Mailing Address - Phone:770-460-2331
Mailing Address - Fax:770-460-4016
Practice Address - Street 1:101 YORKTOWN DR STE 225
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214-1568
Practice Address - Country:US
Practice Address - Phone:770-460-2331
Practice Address - Fax:770-460-4016
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-16
Last Update Date:2021-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA20001558207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty