Provider Demographics
NPI:1669521886
Name:OPTICAL ILLUSIONS, P.C.
Entity type:Organization
Organization Name:OPTICAL ILLUSIONS, P.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:IAN
Authorized Official - Middle Name:
Authorized Official - Last Name:BUCHLI
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:912-264-6000
Mailing Address - Street 1:90 VILLAGE AT GLYNN PL
Mailing Address - Street 2:
Mailing Address - City:BRUNSWICK
Mailing Address - State:GA
Mailing Address - Zip Code:31525-1993
Mailing Address - Country:US
Mailing Address - Phone:912-264-6000
Mailing Address - Fax:912-264-0808
Practice Address - Street 1:90 VILLAGE AT GLYNN PL
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:GA
Practice Address - Zip Code:31525-1993
Practice Address - Country:US
Practice Address - Phone:912-264-6000
Practice Address - Fax:912-264-0808
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-09
Last Update Date:2014-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT0001798152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000954291BMedicaid
GA000954291BMedicaid