NPIMap

Organization Active NPI

Takle Eye Surgery Center LLC

  • Ambulatory Surgical Clinic/Center
  • Locust Grove, GA
National Provider Identifier
1740776517
Registry record updated Jul 19, 2021
On this page

Key facts

NPPES NPI Registry
Primary specialty
Ambulatory Surgical Clinic/CenterTaxonomy code 261QA1903X
Legal business name
TAKLE EYE SURGERY CENTER LLC
Practice address
1075 Bandy Pkwy
Ste 105
Locust Grove, GA 30248
Phone
(770) 228-3836
NPI assigned
Jul 5, 2018
Last updated
Jul 19, 2021By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jul 19, 2021

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Dr. Leiv M Takle Jr., MDNPI 1609807445
Title
Owner
Phone
(770) 228-3836

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Ambulatory Surgical Clinic/Center 261QA1903X Primary

Addresses

Primary practice location

1075 Bandy Pkwy
Ste 105
Locust Grove, GA 30248

Mailing address

1075 Bandy Pkwy Ste 105
Locust Grove, GA 30248-7036
Phone (770) 282-3590

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in GA

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20190417001644 GA Part B Supplier - Ambulatory Surgical Center 2365783461 Practice locations: Locust Grove, GA

Care Compare: Ambulatory surgical center

Medicare Care Compare
Listed as
Takle Eye Surgery CenterCCN 11C0001515
Medicare certification status
ActiveFrom the Provider of Services file

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
11D2160341Takle Eye Surgery Center, LLC1075 Bandy Parkway, Suite 105, Locust Grove, GA 30248Certificate of waiverJan 8, 2027

National Provider Directory

National Provider Directory

Locations

646 S 8th St
Griffin, GA 30224
Phone (770) 228-3836

1075 Bandy Pkwy
Ste 105
Locust Grove, GA 30248
Phone (770) 228-3836

Practitioners & affiliated clinicians

Practitioners 6

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1530748800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1626652800000",
    "number": "1740776517",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1075 BANDY PKWY STE 105",
            "city": "LOCUST GROVE",
            "state": "GA",
            "postal_code": "302487036",
            "telephone_number": "770-282-3590"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1075 BANDY PKWY",
            "address_2": "STE 105",
            "city": "LOCUST GROVE",
            "state": "GA",
            "postal_code": "30248",
            "telephone_number": "770-228-3836"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "TAKLE EYE SURGERY CENTER LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2018-07-05",
        "last_updated": "2021-07-19",
        "certification_date": "2021-07-19",
        "status": "A",
        "authorized_official_last_name": "TAKLE",
        "authorized_official_first_name": "LEIV",
        "authorized_official_middle_name": "M",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "770-228-3836",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_name_suffix": "Jr.",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "261QA1903X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Ambulatory Surgical",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Locust Grove, GA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 19, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.