Organization
BLAIRWOOD OPTICAL, LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
KRYSTAL LYNN PENLEY LDO2341 (C0 OWNER)
(912) 865-5300
Entity
Organization
Contact information
Practice address
27184 US HIGHWAY 80 W, PORTAL, GA 30450-5247
(912) 865-5300
(912) 865-5336
Mailing address
PO BOX 710, PORTAL, GA 30450-0710
(912) 865-5300
(912) 865-5336
Taxonomy
Speciality
Code
Description
License number
State
156FX1800X
Optician
—
—
332H00000X
Eyewear Supplier
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
LDO2341
LICENSED DISPENSING OPTICAN
GA
Enumeration date
11/04/2021
Last updated
12/07/2021
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