Provider Demographics
NPI:1871762823
Name:DR. TERRY H. WYNNE, OPTOMETRIST, P.C.
Entity type:Organization
Organization Name:DR. TERRY H. WYNNE, OPTOMETRIST, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:H
Authorized Official - Last Name:WYNNE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-227-2924
Mailing Address - Street 1:112 W OAK ST
Mailing Address - Street 2:
Mailing Address - City:GRIFFIN
Mailing Address - State:GA
Mailing Address - Zip Code:30224-4233
Mailing Address - Country:US
Mailing Address - Phone:770-227-2924
Mailing Address - Fax:770-227-2937
Practice Address - Street 1:112 W OAK ST
Practice Address - Street 2:
Practice Address - City:GRIFFIN
Practice Address - State:GA
Practice Address - Zip Code:30224-4233
Practice Address - Country:US
Practice Address - Phone:770-227-2924
Practice Address - Fax:770-227-2937
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-25
Last Update Date:2010-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA0650700001Medicare NSC