Individual
MRS. CAROLE F MEDOU
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
LDO
Contact information
Practice address
57 HURRICANE SHOALS RD NW STE A, LAWRENCEVILLE, GA 30046-5396
(678) 878-3540
Mailing address
1475 BUFORD DR, LAWRENCEVILLE, GA 30043-3719
(470) 535-8540
Taxonomy
Speciality
Code
Description
License number
State
156FX1800X
Optician
Primary
2211
GA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
752180024
PEACHSTATE, WELLCARE, MEDICAID, CARESOURCE
GA
Enumeration date
07/28/2020
Last updated
07/28/2020
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