Provider Demographics
NPI:1871773788
Name:WEST GEORGIA OPTICAL, LLC
Entity type:Organization
Organization Name:WEST GEORGIA OPTICAL, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:HOLLOWAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-323-3491
Mailing Address - Street 1:2616 WARM SPRINGS RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31904-5323
Mailing Address - Country:US
Mailing Address - Phone:706-323-0149
Mailing Address - Fax:706-660-9191
Practice Address - Street 1:2616 WARM SPRINGS RD
Practice Address - Street 2:SUITE A
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31904-5323
Practice Address - Country:US
Practice Address - Phone:706-323-0149
Practice Address - Fax:706-660-9191
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WEST GEORGIA EYE CARE CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-11-08
Last Update Date:2022-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA001254332H00000X
GA030005332H00000X
GA017594332H00000X
GA034249332H00000X
GA039057332H00000X
GA047418332H00000X
GA049643332H00000X
GA054799332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1720041718Medicare UPIN
GA1639192131Medicare UPIN
GA1518920529Medicare UPIN
GA1124046735Medicare UPIN
GA1437112935Medicare UPIN
GA1194788684Medicare UPIN
GA1447278106Medicare UPIN
GA1740243740Medicare UPIN
GA6051580002Medicare NSC