Provider Demographics
NPI:1871802777
Name:EYE MAZ N EYE
Entity type:Organization
Organization Name:EYE MAZ N EYE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LDO/OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ECCLESIA
Authorized Official - Middle Name:LUCIANA
Authorized Official - Last Name:GRANT
Authorized Official - Suffix:
Authorized Official - Credentials:LDO
Authorized Official - Phone:404-432-1772
Mailing Address - Street 1:165 HIDDEN BROOK CT
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30349-4440
Mailing Address - Country:US
Mailing Address - Phone:404-432-1772
Mailing Address - Fax:
Practice Address - Street 1:5534 OLD NATIONAL HWY
Practice Address - Street 2:SUITE B-100
Practice Address - City:COLLEGE PARK
Practice Address - State:GA
Practice Address - Zip Code:30349-3212
Practice Address - Country:US
Practice Address - Phone:404-432-1772
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-27
Last Update Date:2010-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALDO 002273156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1437476868OtherECCLESIA LUCIANA GRANT