Organization
LIL FIVE EYES LLC
Active
Other names
Eye Etc.
Organization subpart
No
Provider details
NPI number
Authorized official
COLAY ANQUANETTE WHITE (OWNER)
(404) 523-3937
Entity
Organization
Contact information
Practice address
484 MORELAND AVE NE, D STE, ATLANTA, GA 30307
(404) 523-3937
(404) 688-3232
Mailing address
484 MORELAND AVE NE STE D, ATLANTA, GA 30307-3421
(404) 523-3937
(404) 688-3232
Taxonomy
Speciality
Code
Description
License number
State
152W00000X
Optometrist
GA002600
GA
302R00000X
Health Maintenance Organization
Primary
002600
GA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1619409729
—
GA
Enumeration date
03/29/2017
Last updated
06/22/2018
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