Blairwood Optical, LLC

Primary specialty

Eyewear SupplierTaxonomy code 332H00000X

Legal business name

BLAIRWOOD OPTICAL, LLC

Practice address

27184 US Highway 80 W
Portal, GA 30450-5247

Phone

(912) 865-5300

Fax

(912) 865-5336

NPI assigned

Nov 4, 2021

Organization subpart

No

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

Authorized official

Name

Krystal Lynn Penley, LDO2341NPI 1932771219

Title

C0 Owner

Phone

(912) 865-5300

Specialties & licenses 2

Addresses

Other identifiers 1

Locations

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

• Krystal Lynn Penley, LDO

  • Optician
  • Portal, GA
  • NPI 1932771219
  NPD Authorized official

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

{
    "created_epoch": "1635984000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1638835200000",
    "number": "1851056865",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 710",
            "city": "PORTAL",
            "state": "GA",
            "postal_code": "304500710",
            "telephone_number": "912-865-5300",
            "fax_number": "912-865-5336"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "27184 US HIGHWAY 80 W",
            "city": "PORTAL",
            "state": "GA",
            "postal_code": "304505247",
            "telephone_number": "912-865-5300",
            "fax_number": "912-865-5336"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "BLAIRWOOD OPTICAL, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2021-11-04",
        "last_updated": "2021-12-07",
        "certification_date": "2021-12-07",
        "status": "A",
        "authorized_official_last_name": "PENLEY",
        "authorized_official_first_name": "KRYSTAL",
        "authorized_official_middle_name": "LYNN",
        "authorized_official_title_or_position": "C0 OWNER",
        "authorized_official_telephone_number": "912-865-5300",
        "authorized_official_credential": "LDO2341"
    },
    "taxonomies": [
        {
            "code": "156FX1800X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Technician/Technologist, Optician",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "332H00000X",
            "taxonomy_group": "",
            "desc": "Eyewear Supplier",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "LICENSED DISPENSING OPTICAN",
            "identifier": "LDO2341",
            "state": "GA"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• East Georgia Emergency Physicians PC
• Jessica Hiller, LPC
• Christopher Adam Hogue, LPC, NCC
• Benjamin Kyle Page
• Krystal Lynn Penley, LDO

• All providers in Portal, GA
• Eyewear Supplier in Georgia

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 7, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.