Provider Demographics
NPI:1962762328
Name:LOGANVILLE EYECARE, PC
Entity type:Organization
Organization Name:LOGANVILLE EYECARE, PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ALVIN
Authorized Official - Middle Name:LEWIS
Authorized Official - Last Name:FREY
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:770-554-3456
Mailing Address - Street 1:4495 ATLANTA HWY
Mailing Address - Street 2:SUITE 300
Mailing Address - City:LOGANVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30052-6736
Mailing Address - Country:US
Mailing Address - Phone:770-554-3456
Mailing Address - Fax:
Practice Address - Street 1:4495 ATLANTA HWY
Practice Address - Street 2:SUITE 300
Practice Address - City:LOGANVILLE
Practice Address - State:GA
Practice Address - Zip Code:30052-6736
Practice Address - Country:US
Practice Address - Phone:770-554-3456
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-19
Last Update Date:2018-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT001189152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00716185BMedicaid
GA00716185BMedicaid
GA202G709433Medicare PIN