Provider Demographics
NPI:1437346335
Name:MOG VISION CENTER INC
Entity type:Organization
Organization Name:MOG VISION CENTER INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JIMMY
Authorized Official - Middle Name:
Authorized Official - Last Name:PURVIS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:678-643-6116
Mailing Address - Street 1:844 OZORA RD
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30045-6650
Mailing Address - Country:US
Mailing Address - Phone:404-402-7870
Mailing Address - Fax:770-872-7463
Practice Address - Street 1:844 OZORA RD
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30045-6650
Practice Address - Country:US
Practice Address - Phone:404-402-7870
Practice Address - Fax:770-872-7463
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-25
Last Update Date:2017-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA4615350001Medicare NSC